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Please print or type. <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number <br /> WASTE MANIFEST CAL000401855 1 (877) 577-2669 1 013657400 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Marshalls #M0381 Marshalls#M0381 <br /> (209) 365-0992 2429 West Kettlemen Lane 2429 West Kettlemen Lane <br /> Generators Phone: Lodi, CA 95242 Lodi, CA 95242 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc MNS000110924 <br /> 7.Transporter 2 Company Name !� /'�� U.S.EPA ID Number <br /> f f <br /> / �( /,<<z-ter, ,� �. �l/!'�'J �%✓`�'�� %'f'� <br /> 8.Designated Facility Name and Site Address d1st Uentury EMN, U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facility's Phone: 7755752760 NVD980895338 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.NOI. 13.Waste Codes <br /> X1 UN1993, Waste Flammable liquids, n. o. s. 1 DF 0006E P 341 D001 D03 <br /> C) (ALCOHOL, ACETONE), 3, PG II, ERG#128 <br /> t � <br /> z <br /> 12. <br /> 3. <br /> 4. <br /> ( <br /> 14.Special Handling Instructions and Additional Information 1. 102337(Flammable Liquids) <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the 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 Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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 (ifl am a small quantity generator)is true. <br /> Generator's/_ eror'sPrinted/Type Name Signature beha f of TJX Month Day Year <br /> J 16.International Ship m nts <br /> G! 1 3 20 9 <br /> Z ❑ port to U. S. ❑Export from U. ort of entry/exit:IV <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLJ <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> a Johnny Harper <br /> Zre Transporter 2 Printed/Typed Name ^ Signa Month l Days Yeaar0 9 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> F 18b.Alternate Facility(or Generator) Manifest Reference Number: U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w 1 <br /> p 2. 3. 4. <br /> �-[I� <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedfTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. <br /> 8700-22_12v3 CAL40000131 S40024600 041578068 M PD103119 6D103119 <br />