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1fill <br /> 69425 19 1111111111002f6345144PSC1111I1111 3832042-001 <br /> ,, prat i cr iype. 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 . 002634544 PSC <br /> `.GenPraiors 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)369-1386 LODI,CA 95240 2093691386 <br /> i;eneralix.'s PhCi'i; <br /> 6.Transporter I Company Nana. U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924 <br /> 7.7Yatasf}prt!>r 2 Company Name (' ,�— U.S.fi:PA It)Number <br /> 8.Di Sic v 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 /> f ar; <br /> q;n t..h. '.«.001 Description(including Proper Shipping Name.Hazard Class,ID Number, 10 Containers 11.Total 12.Unit <br /> tri <br /> an(!Parkin(Grum(if any) 13.Waste Cortes <br /> No. Type Quantity wt./Vol. <br /> 1 UN2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII <br /> 331 D006 t D008 <br /> X 1 DF 104 P - ..... ....,_._. <br /> LU <br /> {€F <br /> i <br /> ; :iai Hari;fi;ing fnctru::tions<rnd Additional Informal.ion <br /> (1)ROSS6.1-07'ERG(153)ROSS6.1.07-TOXIC LOOSEPACK <br /> ;. GENE RAIOR`SIOFFEROR'S CERTIFICATION: I hereby declare that[tie contents of this consignment are fully and accurately described above by the proper shipping name;and are classified,packaged, <br /> rurxlcad,i d larefodl placarded,and are in all respects in proper condition For transport according to applicable international and national govemmental regulations.If export shipmen!and I am the Primary <br /> !..xporier,I ceai`y that the content:of this consignment conform to the terms of the attached EPAAcknoivledgment of Consent. <br /> I r�r.rtify that the waste rimirniiation statement identified fr 40 CFR 262.27(x)(if1 am a large quantity generator)or(b)tiff am a<:rnali quantity generator)is true <br /> en ra i—nn rs ^ntc('.I:, Nam,^. ` „( Signature Month Day Year <br /> U Jam\ E-1-1TV 12 31 19 <br /> _j 16.I .rational Sh!prnents 1:1 Import to U.S. ❑Export from U,S. Port of entryiexit. ....______ <br /> i ear.f;nrier signature(for exports only). Date leaving U.S.; <br /> cc if ranspoE tr r t;^kno,vfedyment.of Receipt of Materia.'fs <br /> LU <br /> T„n ;;ilii 1 printed?i'yped Nanne Signature Month. Day Ysar <br /> c.' Andy Winkler 12 31 19 <br /> 2 Iia+, .P n,ed'fypee tlarne Signature Month On Year <br /> .t <br /> indicalion Space <br /> ❑ Quantity ❑? :r ❑Residue ❑Partial Rejection ❑Ful;Rejection <br /> Manifest Reference Number: <br /> Fes- faribi'y for Generator) <br /> U.a EPA ID Number <br /> t 3c' at:!re:of Alternate,Facility for Generator) Month Day Year <br /> F— <br /> 19 firrl,amous Waste,Report Management Method Cods(Le.,codes for hazardous ivaste,treatment,disposal,and recycling systems) <br /> i. r. 3 4. <br /> H141 <br /> ;inated Facility Owner or Oiler or Ced;ication of receipt of hazardous materials covered by the manifest except as n d in Item'18a <br /> PrEnreii Pvt"Od Male Si nature <br /> 9 Month Dau a. <br /> c <br /> r r (cam;1700 22(Rev,12-17) Previous editions Ore obs le. D SIG D FA ( SPA',e-MANIFEST SYSTEM <br />