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424676:19 3 n■-uralu■nnminnmI1N111111 <br /> 002443874PSc E' 3683613-001 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number r2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000397504 (877)577-2669 002443874 PSC <br /> 5.Generator's Name and Mailing 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)369-1385 LODI,CA 95240 2093691386 <br /> Generators Phone: <br /> 6.Transporter t Company Name U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> S .'T ca ItiOp 0315 <br /> B.Designated Facility Name and Site Address U.S.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 /> Facility's Phone: <br /> 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity wt./Vol. <br /> 1. UN3139 WASTE OXIDIZING LIQUID,N.O.S.(HYDROGEN PEROXIDE)5.1 PGI <br /> i OO )( r D001 <br /> 8 P <br /> UJ �✓ <br /> _ Z 2. UN2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII <br /> C9331 331 D006 D008 <br /> 1 DF 117 P <br /> D011 D016 <br /> 3. <br /> i <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> (1)ROSSOXIUQ-07-ERG(140)ROSSOXIUO-07-OXIDIZER LOOSEPACK(2)ROSS6.1-07-ERG(153)ROSS6.1-07-TOXIC LOOSEPACK <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,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 /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator]or(b) if I am a small quantity generator rue. <br /> Generator�ffes ndt-e-ffyped ame ignatu Month Day Year <br /> K� <br /> 16.I onal Shipments <br /> 8 23 19 <br /> z ❑Import to U.S. ❑Export from U.S. Port of entry/eA: <br /> Transporter signature(for exports only): Date leaving U.S.: ^- <br /> CC UJ <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Nam <br /> e Signature Month Day-Year <br /> a <br /> GelryrGrresei� `. ��C� Lr 8 23 10 <br /> Transporter 2 Printed/Typed Name Signature Month Day Year <br /> 18.Discrepancy Okla )CI <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection <br /> J ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> J U.S.EPA ID Number <br /> U <br /> L6 Facility's Phone; <br /> LOW 18c.Signature of Alternate Facility(or Generator) <br /> a Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1 <br /> H070 2. 3. 4. <br /> H141 <br /> 20.Design ted Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Print IT eddNNamee Signature Ye <br /> w! <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's a-MA IF ST SYST M <br />