Laserfiche WebLink
III11IIl111N1M11iI11111all 2972392-001 <br /> 759237-17 001702s17PSc <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 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 (877 577-2666 001702917 PSC <br /> 5.Generators Name and Maaing 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 /> Generators Phoneomp; . <br /> any <br /> Transporter6. U_S.MAID Number <br /> STERICYCLE SPECIALTY.WASTE SOLUTIONS INC MNS000110924 <br /> 7.Transporter 2 Company Name: U.S.EPAID Number <br /> 8.Designated Facility Narne 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 /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13. Waste Codes <br /> HM and Packing Group(ff any)) No. Type Quantity Wt.Nol. <br /> 1. NON RCRA HAZARDOUS WASTE LIQUID(WATER BASED PRODUCTS) 331 <br /> IX 1 DF 30 P <br /> aO <br /> OG <br /> W r. <br /> 3 <br /> 4. <br /> 14.Special Handling Instructions zndAdditional Information <br /> (1)ROSSNONREG-04-ERGO NON RCRA/DOT REGULATED MATERIALS(2)R0661110RIi"r-601 04 <br /> (3h <br /> 15. GENERATOR`S10FFER0R'$CERTIFI ATiON: I hereby declare that the contents of this consignment are fulry and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and tabeled/placarded,and are in all respects in proper condition for transport according to.applicable international and national governmental regulations.If export'shipmentond 1 am the Primary <br /> Exporter.I certify that the contents of this consignment coriform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement idenfified,in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(d I am a small quantity generator)is true. <br /> Month ear <br /> 00 tors/ erors Prin /Typed ame <br /> 11 13 17 <br /> 16.Interriaficifial Shipments; El Dort to U.S' 0 Export from U.S. <br /> . Prof entry/exit: <br /> in U.S. <br /> :ry <br /> Transporter signature for exports on <br /> 17.Transporter Acknowledgrnentof Receipt of Materials on ear <br /> a Transporter 1 Printed/fyped gra 11 13, 17 <br /> ZDarryl Johnson ear <br /> Transporter 2 PrintedfTyped Name ign <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication.Space Quantity. ElType ❑"Residue ElPartial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPAID Number <br /> 18b.Alternate Facility(o Generators <br /> J <br /> V <br /> Facility's Phone: Month Day Year. <br /> W18c.Signature of Alternate Facility(or Generator) <br /> S219.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,distasal,and recycling systems) <br /> G 1. 2. 3. 4' <br /> H141 CY <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Mon Day <br /> Y <br /> Printed,Typed Name Signature <br /> EPA Form 87 2(7v.3-05) Previous-editions are obsolete. <br />