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IIIIIIIloll11111111111111 <br /> 535904-19 II002544166PSC 111111111 3743725-001 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000397504 1 (877)577-2669 002544166 PSC <br /> 5.Generators Name and Mailing Address Generator's 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's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924 <br /> kporter 2 Company Name U.S.EPA ID Number <br /> �"s e-a o -3sc; <br /> Designated Facility Name and Site.Address U.S.EPA ID Number <br /> 219t Century Environmental Management of Nevada LLC NVD980895338 <br /> 2095 Newlands Dr.East, <br /> Fernley NV 89408 (775)575-2760 <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12 Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt,/VOI. <br /> 1, UN2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII <br /> p� 331 D006 D008 <br /> OO X 1 DF 160 P <br /> D011 D016 <br /> Z l <br /> Z <br /> W <br /> CD <br /> r <br /> 14.Special Handling Instructions and Additional Information <br /> (1)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 /> I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(if l am a small quantity generator)is true. <br /> Genera 's/Offeror's Prioted/Typed Name Signature Month Day Year <br /> .Je rq <br /> 10 15 19 <br /> 16.1 ational Shipme is <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exi. _____ <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> LJ 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed1Typ e ` Si a(u Month Day Year <br /> a 10 15 19, <br /> r Transporter 2 Printed7fy,ed N me Signature Month Day Year <br /> !S 119 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑FUII Rejection <br /> Manifest Reference Number <br /> 1 Bb.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> v <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJI 1. 2. 3. 4. <br /> H141 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the mani st except as noted in Item 18a <br /> Printed/Typed Nam k (w) <br /> Sign tore Month Day Year <br /> 'C) vNI !'jQCJ <br /> EPA Form 8700-22(Rev.1 -17 Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />