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5359$1 1:9 nnnrnlls�� r�lacwillIII �.•�+ <br /> ISS W. <br /> Please: print or Pei FormAppfove(i.•0'8 No 205, <br /> UNIFORM HAZARDOUS 1..Generator ID Number 1.2.,Page 1 of 3.Emergency Response Phone 4 Manifest Tracking,Nwn6erWASTE MANIFEST CAL000397504 1 (877)577-26690025442"PS <br /> 5.Generators Name and Mailing AddressGenerators 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 /> Geneealors Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLU71NS INC MN$000410924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> GENERAL ENVIRONMENTAL MGT LLC DBA PSC ENVIRONMENTAL SERVICES CAD980884183 <br /> 11855 WHITE ROCK ROAD, <br /> RANCHO CORDOVA CA 95742 (916)351-0980 <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity wt./Vol. <br /> 1. <br /> UNI 900 WASTE AEROSOLS 2.2(8) <br /> 331 0001 <br /> 2. UN799 WAgft FLAMMABLE LIQUIDS,N.O.S.(ACETONE)3 PGII <br /> -t:1 ;t70Q1 <br /> X - 1 DF .28 P.. 331 <br /> 4: <br /> 14 Special Handkrglnstrtictions and Additional Information <br /> (1)ROSSAERO 07'-ER"Z6j ROSSAERO 07-AEROSOLS(2)ROSSFLAMM-07-ERG(128)ROSSFLAMM-07-FLAMMABLE LOOSEPACK <br /> 15 Of NERATQRS(OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fuly and accurately described above by the proper shipping name,and are classified paeKagedr <br /> marked and iabeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.if export shipment and I am the Pfirrfary. <br /> Eieriorter,!certify that the contents of this consignment conform to the terms of the attached EPAAekn%*dgment of Consent.. <br /> I certify that the.waste minimization statement identified to 40 CFR 262.27(a)(if J am a large quantitygeneretor)or(b)(if I am a small quantitygenerat6d is-true.. <br /> Generatoes/CNfemrs Pi tednyped.Name /� g <br /> Year <br /> ul 1 - <br /> ..` � y V Mon <br /> 10 15 19 <br /> 16.International Shipments ❑ <br /> F- -- - - - - Import to U.S. - ❑Export from U.S. -- Port ofentry/ex$: - <br /> —--— --- <br /> Transporter signature(for exports only). Date leaving U.S.: : <br /> C 17.Transporter Ackriml dgmentof Receipt of Materials <br /> Transporter T PnntedfT e <br /> CL �9n. tf►. Day Year. <br /> cn eoI+GTdS9i Y`r.1 '! �A. :..1 <br /> z Transporter 2 PnnteNTyped Name It.. 8 <br /> *. Month. Icy ': Year <br /> H - <br /> 18.Discrepancy 7 70 <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑PartfatR'ection <br /> el ❑ <br /> FuµReJeetixr <br /> Manifest Reference Nu <br /> 18b.Alternate-. <br /> (or Generator) mtfer: <br /> =r U.S.EPA ID Number <br /> CU <br /> L Facility's Phone: <br /> LOU 1&.Signature of Alternate Facility(or Generator) <br /> �' Month'. Day Year <br /> N19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj: 1: 2 <br /> S <br /> H741 H141 4. .: <br /> 20 Designated Facility Owner or Operator:Certcation of receipt of ha.7,ardous materials covered by the manifest except <br /> as rlded in Item T88' <br /> PcinfedlTyped Name <br /> Sipature <br /> MonUr Day "Year <br /> k�i <br /> EPA Farm 8700-22(Rev.12.17).Previous editioris ace obsolete DES! fiEQ FACILITY TO.EPA's e=MANIFESTS:1/STEM' <br />