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96310-2Q It111111111annnrinnnlI1n■n.0 3887071-001 <br /> r' 002693009PSC - <br /> 4 lytie. " Form Approve (1 <br /> d"OMB No.20.10039 <br /> ` tINIFf1E2M HAIAROOtIS <br /> 77- A <br /> `r , lf)N,jnil)cr 2.Paye i of 3-1 r a,n( Tt..un as��Phone 4.Manifest Trackin Number <br /> 4JASfF �9ANIFfST CAL000397504 1 (877)577-2669 002693009 PSC <br /> i <br /> - Generalor s Site Addiess(n dillerent than maiio)g addcess) <br /> ROSS STORE#0477 ROSS STORE#0477 <br /> l 340 W KETTLEMAN LN 340 W KETTLEMAN LN <br /> LODI,CA 95240(209)369-1386 LODI,CA 95240 2093691386 <br /> i <br /> ' r)v,o';N0111(' t i S.I-PA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924 <br /> u.s.ERA ID Number <br /> .--, <br /> T _ <br /> b'. Name ill(I Site Addrr; U.&EPA ID Number <br /> 21st Century Environmental Management of Nevada LLC NVD980895338 <br /> 2095 Newlands Dr. East, <br /> Fernley NV 89408 (775)575-2760 <br /> WS WT i cSiiippoy Name.(!hard Class,f!)Nirihei, 10 Container: 11 Total 12 UnB <br /> r J.viasin <br /> No, Type Quantity Wt Vol. <br /> i UN2810 WASTE TOXIC,LIQUIDS.ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII <br /> 331 1 D006 D008 <br /> X 2 OF 223 P _.,......,.... .... _... <br /> D011 D016 <br /> LU <br /> Z <br /> LU <br /> i <br /> a <br /> 7 <br /> 'I !t,andiirr)1i s�r,:'nn qnd Additown!.r <br /> (1)ROSS6.1-07-ERG(153)ROSS6.1-07-TOXIC LOOSE PAC K <br /> GENLRATOR'SIOFFEROR'S CERTIFICATION: (!!t retry declare that.the contents of[his consignment are fully)r1d accurately desciihed above by the proper shippingnarnn ar i are ciass!f!ed,package(i, <br /> n1 iKr(i kind inbelra'plaearde(I.and are in ail respects na proper condition for transport according to applicable international and national governmental regulations.if export shipment and I am the P)navy <br /> I certify".hat rhe coni entsof this consignment conform to the lerms of the atlached E PAAcknowledgment of Consent. <br /> r!'Iy that the vraste minimization sta'emr.nt idertd!ed In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if lam a small quantity generator)is time. <br /> �� cr, r,n,ed=Am+tf N• ,' r SigFiat t,4ont!1- Day Year <br /> 2 25 20 <br /> i ❑ih.)n;rl to U.S. Elf xpo,,[from U.S. Poll of enlrriexit --—_ <br /> .........:....... <br /> Dale loaving U.S-: <br /> i� ire!x )i�.:6erkrs?rirlrnenlrif;eceipturfllfEnais <br /> w <br /> 77777­1r, �)'e rr,ped Name Signature Month Day year <br /> Q Andy Winkler A>6'PJ2 25 20 <br /> f p d Name 7� Signature 7 YeMonth Ua ar <br /> /'0zLinc Z 2 <br /> " <br /> I._.-) r antity El 1'yllr' ❑Rosiclac ❑Partici Rejection tl F1!ll Rejection <br /> Manifest Ref(,rer!ce Number: <br /> C&"eralor) 11 S.EPA ID(dumber <br /> C.7 <br /> f ALT rqIL I lr:iii nr Geireralnr) <br /> Month Wy, "ear <br /> t) - :,4`J<,s n itrpc>a.�i i�x) rae)'htiinthod C."qr ,":,nGdcs tL.hrazarciotu vJtlste frr atment,dn;posaf and�r yr,linrl.y,fen?:>} _ <br /> H141 3. <br /> ri ;pit i C f 9.:Lity Ov.ner or Ope.ralOI C001i!i:alinn of receipt of hazardous materials Covered by the manifest except aS ote(i i!7 Item lf1{) <br /> ):ed%i ari <br /> Name gnahare <br /> Month Day `kar <br /> r'i F r}I);3 rfi+,22 Q2ev..2-.r') F revicuis ecGtitn). ' .obsolete. s1G E€3 ELITY T{?EPA`s e N1AjFE <br />