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752972392-001 <br /> $' y »:'. 001702931 PSC <br /> Please prinCor tyae (1 qrm wed for use on elite(12-pitch}typewriter.) Form Approved:) No.2050-0039 <br /> UNIFORM HAZJDOUS, Generator ID Number 2.Page.1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST: CALOW397504 1 (877)577-2669 0017 2931 PSC <br /> 5:Generator's g dress = Generators Site Address(if different than mailing address) <br /> i ROSS STORE#0477 <br /> ROSS STORE#Q477 . ..; <br /> 340 W.KETTLEMAN LN <br /> 340 W KETTLEMAN tN LODI,CA 95240 209369138& <br /> LODI, CA 95240 3l1W11386 <br /> Generators Phone: <br /> Transp6der' orllp ameUS.EPA ID Number <br /> ; <br /> STERICYCLE SAEC!¢I:T1f WASTE SOLUTIONS INC' MN$()00110924 <br /> 7. <br /> U.S.EPA 11Trans r 2 Company ..- <br /> Number <br /> 8.Designated Facility Name and Silleflhddress U.S.E A.ID Number <br /> 21st Century Environnlental Management of Nevada LLC NVD980895338 - <br /> 2095 Newlands Dr.East, <br /> Fernley NV 89408 (775)575-2760 <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 /> HIM and Packing Group(-deny)). No. Type Quantity Wt/Vol. 13. Waste Codes <br /> 1. UN1993 WASTE FLAMMABLE LIQUIDS,N.O.S.(ACETONE)3 Pat <br /> . 331 0001 <br /> '0 X 1 OF 22. P <br /> LU <br /> Z: 2. UN1$50 WASTE AEROSOLS,FLAMMABLE(EACH NOT EXCEEOING 1 L CAPACITY)2.1 <br /> LLA 331 D001 <br /> C9. X 1 OF 8 P <br /> 3. ON2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII <br /> 331 D006 D008 <br /> X 1 OF 93 - P <br /> D011 . D016 - <br /> 4. <br /> 14:Special Handling Instructions and Additional Information <br /> (1)ROSSFLAMM-O6=ERG(128)FLAMMABLE LOOSEPACK(2)ROSSAERO-05-ERG(126)AEROSOLS(3)ROSS6.1-05-ERG(153)TOXIC LOOSEPACK <br /> 15. GENERATORVOFFEROR'S CERTIFICATION::I hereby declare that the contents of this consignment are fully and accurately described above.bythe proper shipping name,and are classified,packaged, <br /> marked and labeled/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 Ptimary <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 CER 262.27(a)(d I am a large quanti enerathr)or(b)(it I am a small quantity generator)is true- <br /> eratorsl erorsPrinted Name ure Month- Day Year <br /> Al <br /> f/� 11 13 17 adus <br /> J 6.Intemat al Shipments <br /> i- ❑Import to U.S. ❑Export from U.S: ort of entrylexit: <br /> Z <br /> Transporter sinature for exports only): Date eavinU.S.: <br /> w, 17;Transporter po Acknowledgment of Receipt of Materials <br /> Transporter 1 PdrigWryped Mame ign e Month Day year <br /> N Darryl Johnson: 11 13% 17 <br /> Q Transporter 2 Printedfryped Name Month Yes <br /> +x , Grp fa <br /> 18.Discrepancy ((�� <br /> i 8a.Discrepancy Space El Quantity ❑Type 1:1 Residue' C Partial Rejection ❑Full Rejection <br /> 18b.Altemate Facilityor Generator <br /> Manifest Reference Number, <br /> ( ) U.S.EPA ID Number <br /> Ll <br /> �a+ Facili 's Phone: <br /> W 18c:.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> �- 1.• 2. <br /> 3.' 4 <br /> H1.; H141 H741 . <br /> 20.Designated Facility Owner or.Operator.Certification of receipt of hazardous materials covered by the manifest exLasted in Item 1 a <br /> SgnatMonth -Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br />