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Lj5j: 7L <br /> -309904-19 002357388PSC 3619983-001 <br /> Please print or typd:' Form Approved.OMP No 2050-0009 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000397504 1 (877)577-2669 002357388 PSC <br /> 5.Ger:.oraior's Name and Mating Address Generators Site Address(if different than mailing address) <br /> ROSS STORE#0477 ROSS STORE#0477 <br /> 340 W KETTLEMAN LN 340 W KETTLEMAN LN <br /> LODI,CA 95240(209)369-1386 LODI,CA 95240 2093691386. <br /> Generator':;Phune: <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924 <br /> •'.TrwNporter 2 Company Name ✓ , 1'� U.S.EPA ID Number <br /> �Z4 / may Aro� oj"�, 't�'Y <br /> 8.De sign red Facility Name and Site Address U.S.EPA ID Number <br /> 21 st Century Environmental Management of Nevada LLC. NVD980895338 <br /> 2095 Newlands Dr.East, <br /> Fernley NV 89408 (775)575-2760 <br /> Facility's Phone: <br /> ya_ 9b:U.S.DOI Description(including Proper Shipping Name.Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> M and Packing Group(if any)) No. Type Quantity Wt.lVOI. 13.Waste Codes <br /> HM <br /> 1 UN2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII <br /> � 331 D006 D008 <br /> O X 1 DF 67 P - t — <br /> Q D011 D016 <br /> CC <br /> tr.t <br /> UN3264 WASTE CORROSIVE LIQUID,ACIDIC,INORGANIC,N.O.S.(HYDROCHLORIC ACID, <br /> PHOSPHORIC ACID)8 PGII 791 D002 <br /> X1 DF 11 P ......,...,...,._,.._.m..,.._..__._...,_„._, <br /> 1 <br /> 3. UN1993 WASTE FLAMMABLE LIQUIDS,N.O.S.(ACETONE)3 PGII 331 D001 <br /> i <br /> I I <br /> 4. <br /> I <br /> 14.Special Handling Instructions and Additional Information <br /> (1)ROSS6.1-07-ERG(153)ROSS6.1-07-TOXIC LOOSEPACK(2)ROSSACID-07-ERG(154)ROSSACID-07-ACIDIC CORROSIVE LOOSEPACK(3)ROSSFLAMM-07-ERG(128)ROSSFLAMM- <br /> 07-FLAMMABLE LOOSEPACK <br /> i 5. GENERATOR'SIOFFEROR'S CERTIFICATION:t hereby declare that the contents of this consignment are,fully anq accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled!vlacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> E;:porter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I cer:itt Thal the waste minimization statement identified in 40 CFR 262.27(a)(if i am a large quantity generator)or(b)(if I an a small quantity generator)is true.. <br /> Gcnerator' C ffc.ror's PrintW4k+yoed Name1���� S;gnalur Month Day`� (�J,(� 6 18 19 <br /> ifs.International Shipmeirts' <br /> ❑Import 10 U.S. ❑Export from U.S. Port of entry/exit: <br /> - - -- <br /> z mnspOrE ignature(ler exports only): Date leaving U.S.: <br /> cY <br /> L% transporter Acknowledgment of Receipt of Materials <br /> 1.anspoder 1 PrintedlTyped Name Sir e Month Day Year <br /> nQ Z pip <br /> , 6 18 19 <br /> taT "OA3 A i <br /> nsporyped <br /> Name �' r i ature Mon h Day Year <br /> 18.Discrepancy <br /> 18a Discrepancy Indication Space <br /> ❑ Quantify F]Type. ❑Residue, ❑Padiai Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> IRU Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Ldc.. Fa(ilitySPhOne: - - - <br /> 18c Signature of Alternate Facility(or Genera(or) Month Day Year <br /> Q <br /> Z <br /> U <br /> rn 19 I lazardous Waste Report.Management Method Codes(i.e.,codes for hazardous waste treatment,disposal.and recycling systems) <br /> 1. H141 2 H121 31 <br /> H141 4. <br /> ?0.D(!sil,inated Facility Owner or Operator.Certification of receipt of hazardousmalerials covered by the manifest except as noted in Item 18a <br /> Prin(ecl-Type: ae Sici Month Day Year <br /> EPA Form 810()-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />