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583 -1� II11111111I1111�IN11NIIIIIIitIII111 - <br /> ! <br /> 002572155PSC 3771648-001 Please print,or type. Form Approved,OMB No.2050-0039 <br /> UNiFORM'fiAZAfiDOUS 1.GeneratorID Number 2,Paye I of 3.Emergency Response Phone 4.Manifest TrackingNOmber <br /> WASTE MANIFEST CAL000397504 , % (877)577-26.69 002572155 PSG <br /> 5,Generator s Name and Mailing Addreis 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 /> 8.Transporter 1 Company Name <br /> U.S.FPA ID Number <br /> STERICYCLE SPECIALTY WASTE.SOLUTIONS INC MNS000110924 <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA IDL 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'aPhone: , <br /> F . ga 9b.U.S.DOT Descnplxul(irlchidingProper;Shipping Name,Hazard Class,ID Number, 10 Containers 12.UnitHM and Packing Group(if any)) 11 sofas No. Type quantity v.1Vot 13.Waste Godes <br /> 1 1JN2810 WASTE TOXIC,LIQUID$, NC,N.O.S.(LEAD,SILVER)6.1 PGII <br /> X <br /> I rY 331 D006 D008 <br /> I Q _ - 1 ; <br /> ( DF 83 P . <br /> DObt D016 <br /> j ;z 2: <br /> Ip ; <br /> 4. <br /> 14.Spegal Handling Instructions and Addition;]Information' <br /> (1)ROSS6.1-07-ERG(153)ROSS6.1-07-TOXIC LOOSEPACK <br /> I <br /> 4. <br /> i 15: .GENERpTOR'S1flFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name aril a <br /> marked and labelere classified,packaged, <br /> ' d%placarded,and are m all respects m 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(a)(if I am a large quantity generator)or(b)(9 t am a small quantity generator)is true <br /> Generalor rs P ed/fyped Name Si Month Day Year <br /> u, �G. � '�� 11 14 19 <br /> -a FIXAternational Shipments.` ( , <br /> F— - ❑Import to-U S ❑Export from U.S.. Port of ent !exit: - <br /> Z Transporter signature(for exports only): ry -: — -- <br /> -- <br /> Date,leaving U.S. <br /> CC 17.TmnsporterAcknowledgment of Receipt of Material. <br /> Transporfei t Printedlry, ame Signature <br /> < Month Day Year <br /> CL Cory Grassi, T1. 19 <br /> Transporter 2 Printedffype ame 14 <br /> Signal <br /> Month Day Year. <br /> IL <br /> 18.Discrepancy C . Zf9 <br /> I&a,Discrepancy Indication Space <br /> El quantity ❑Type ❑Residue ElPartial Rejection <br /> ❑FuII Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Roterence Number: <br /> -r U.S.EPA ID Number <br /> U <br /> Facditys PholTe; <br /> yuj 18c::Signature:V Aternate Facility(or Generator) <br /> Z Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes foi Hazardous waste treatment;disposal,aril recycling systems) <br /> W 1 <br /> H141 2' 3 .. 4 <br /> 20.Designated Facility Otmer or jperalor.Certification of receipt of hazardous materials covered by the manifest except as not in Item 18a <br /> PrintedrTyped Name <br /> Signature <br /> M Day n <br /> EPA Form 8700-22(Re .12-1 } Previous editions e obsolete. S� <br /> D NA FACILITY TO EPA's e- A FEST SYSTEM <br />