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nnmInmulmnoonnisIIIm 3804582 001
<br /> 643840-19 002605201 PSC
<br /> Form Approve(i.OMB No ) 0 UO,;(i
<br /> lNIFORM HA7AFtD(}US I s i,.r,r,nr ID Number t Page 1 i>1 3.!".mf !<n.,Re•sl is+r Phone 4.Manifest Tracking Number
<br /> �IASTF MANIFEST CAL000397504 1 (877)577-2669 002605201 PSC
<br /> t 1.1:1snc, ? 6enerau is Site Address(if drffe:ent than rn r't,add:
<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 /> oc•fk 1 C;omiiany Name U.S.EPA ID Numbir
<br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924
<br /> Tran:>por!r :.'.Company Nmne ,,. _ v U.S EPA.ID Numb;n
<br /> ,N:m ant! 1 Arrlres 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 /> ;)t t;, u'-g irrn r•Ships, Name,idazard(;:a s,ID Number, iG Ccnt,uners I! Tatal 12 Unit
<br /> 13.Waste Codes
<br /> tr No. type Osant:hy l-dt1110.
<br /> UN2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII 331 D006 € D008
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<br /> D011 D016
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<br /> Com^ .,,.._...... ...,.,..,.-..._..-..s..._._._.,.,,.
<br /> ,:!tot,n- r :.;c.,t;Information
<br /> (1)ROSS6.1.07-ERG(153)ROSS6.1-07-TOXIC LOOSEPACK
<br /> i
<br /> GENERATOR'StOFFEROKS CERTIFICATION: i hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name.arxf are cI<€s;;iired,frtckeleed,
<br /> n,trkr :i € :+i;e'pd,r!ecrtrcfed,and are in a!l respects in proper mndilion for transport according to applicable international and national governmental regulations.If export shipment and I am h10 Pr mazy
<br /> t ic-contents c•f ti r c n r.gnnu nt r o tfomt to the,terms of the attar bed EPA Acknowledgment of Consent
<br /> il-ni Inc.,a,'r,ot.n3r,v loon star me t identified in 4O CFR 262.27(a)(if I am a I age quantity generator)or(b)(if I am a small quantity generator)is true.
<br /> l yp Name S- lure t+,4onil'. p ,f,9
<br /> 12 12 19
<br /> ❑it}r,t'rt t_)S. .xpr;d from U.. Pr,t,of er, 'exd.
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<br /> (tor r "o is only): Dare,caving U.S.:
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<br /> 00, 12 12 19
<br /> z tr r•;�ori+"%.;''soleiyped Name J _ „ - Si ' ure Mnn(h pay yr,c}r
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<br /> c.,,'+?r: I,uiirtu,r.o7at.l' � fl.nn0(y ❑1;,^, ❑Residue
<br /> ❑i'arhal Rejerhon ❑Full Rr)edinr
<br /> Manifest Reference Number:
<br /> US.EPA ID Number
<br /> 43
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<br /> t°-,riff} Da--iY_!a;
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<br /> Man., t A94,fhf,d Codes( r:,Hades:foi bizarrllousomste treatment,disposal,and recyrlirlg sy>tcr;)c)
<br /> 2. 3.
<br /> H141
<br /> f-a(f ity O.vner or Operator.Cerhlicwion tf re cpipl of hazardous materials covered by the manifest.except as noted in Item 18a
<br /> signature' rA:,r;l..tt Day' Y+rar
<br /> Ila �q
<br /> _` i . ,1 B 00-22 lRe=. 12-17) Previous e rlitusns are obsolete. DESIGNATED FACILITY T�} i° re-MANIFEST SYS?E J",
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