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Please print or type. <br /> 1111111 111111 Form., ro, <br /> I.Generator ID Number or. a c zd.OMB No.2050-0039 <br /> :UN1:F0RM:HA=:ZA:RD0US 2.Page 1 ofE3775772'669 <br /> mergency Response Phone 4.Manifest Tracking Number <br /> TE 1 .582 F L E <br /> ai_tZtk t�lt�'7614 1 <br /> 5.Generator's Name and Mailing Address Generator s Site Address(if different than mailing address) <br /> Bath Body Works 65 Bath n Body Work5#65 <br /> 209952'4396 5?I[I$ FrACIFIC AVE. SHERWC10D NALLi SPIPCE 6 5308 PACIFIC AVE <br /> Generators Phone: STOCKTON. CA 95207s t <br /> 6.Transporter 1 Company Name STOCKTON. CA 95207 <br /> U.S.EPA ID Number <br /> ^ nLIP^}a nl r 2' ' nr Tr <br /> 7 Transporter 2 Company Name -` r. V1924 <br /> /?7 <br /> / _ U.S.EPA ID Nber <br /> um <br /> 8.Designated Facility Name and Site Address s row j <br /> .1st Cent�try E,VN, LLQ: U.S.EPAID Number/ <br /> 2095 Newlands Dr. East <br /> Fernley. NV 89408 <br /> Facility's Phone: 7755752761[1 <br /> NVD98t4895-38 <br /> 9a_ 9b.U S.DOT Description(including Proper Shipping Name.Hazard Class.ID Number, <br /> HM and Packing Group(if any)) 10.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt./Vol. <br /> 13.Waste Codes <br /> o X 1' UN199�. Waste Flammable li❑:_rids, n, o, s, (Ethy 1 GF1k3'= F, ?31 rr}� Jktk'l <br /> Hlrohol, Acetone). 3, PIS II. ERG#128 ------ — _.__ <br /> LU <br /> Z 2 <br /> LU <br /> LD <br /> 1 <br /> i <br /> 14.Special Handling Instructions and Additional Information <br /> 1, 110905(Flammable Liorrids) <br /> 15. GENERATOR'Sf IFFEROR'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 intemationaland 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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization s atement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(IN am a small qua y generator)is true. <br /> Generator's/Orieror's Printed/Typed a Signature <br /> CL r r behalf of Limite Month Tay—year(�� <br /> � 16.Internacional Shipmen s <br /> J 1, 201' Y <br /> Z ❑1 port to U.S. Export from U.S. rt of entry/exit: <br /> Transporter signature(for exports only): <br /> Date leaving U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name <br /> Signature Nlonth Day Year <br /> Johnny Hari3er <br /> co z Transporter 2 Printedryped Name lett 1 2'1 1`0 <br /> Sianatur in Day Year <br /> 18.Discrepancy ? <br /> 18a.Discrepancy Indication Space <br /> Quantity U Tyke ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> F 18b.Alternate Facility(or Generator Manifest Reference Number: <br /> .r U.S.EPA ID Number <br /> U <br /> LL Facility's Phone: <br /> W182'.Signature of Alternate Facility(or Generator) <br /> F <br /> z Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment:disposal;and recycling systems) <br /> LU <br /> O 1' 2 3. <br /> 2G.Designated Facility Owner or Operator:Cerhification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedffyoed Name <br /> ` Signature Manth Day Ye—.r <br /> 4//;-1 ! . <br /> / <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. <br /> 8700-21::-•_12v-'7A' <br /> _` <br /> C9.3-178 941067816 04164364' N PD01S 20 r <br /> L Je'._s 04'I It 13120 <br />