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I l� <br /> Please print or type. Ek � <br /> 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 CAL000369901 1 {$77) 577—`669 FLE <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if differem than mailing address) <br /> 99 Cents Only #264 99 Cents C1nly#264 <br /> (209) 478-2133 1449 w March Ln 1449 W. lurch Lane <br /> Geri Phone: Stockton, CA 9 .207--E111 Stockton, CSI 95207-6 .11. <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Ster•icycle Specialty waste Solations inc MNS000110924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address 21St Century EMN, LLC U S.EPA ID Number <br /> 095 Newlands lir, East <br /> Fernley, NV 89408Faciiity's Phone: 775575276 NVD9808953,38 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 1g.Contalnor$ 11.Total 12_Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity wt-Ivol. <br /> X 1. UN1993, Taste, Flammahle 1 igUids, n. a, ss 1 8A L7710-003 P 333 D001 <br /> a (Petrolell Distillates, Alcohol) , 3, PG 11, <br /> � a <br /> w <br /> z 2, <br /> LU <br /> i9 <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1. PKG-,DF w 10 1992(F l am l Liquids) <br /> 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of.his consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and'€abeledlplacarded and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If exportshipment and i am the Primary <br /> Exporter I ce,tify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> ?certify that the waste minimization statement identified in 40 CFR 262.27(0)(if I am a Targe quantity generator)or(b)(If I am a small quantity generator)is true. <br /> GeneralcT'slOfferor's R inted!Typsd Name Signature q Month Day Year if of 99 Cents Only <br /> 16.International Shipments <br /> ❑Import to U.S. Export from U.S. Poo of entrylexil: <br /> ? Transpnrfersignature(for exports only): Date leaving US.: <br /> K 17.Transporter Acknow;edgment of Receipt of Materials <br /> a Transporter 1 PrinfediTyped Name Signature Month Day Year <br /> a Jeff Hamilton �1 i' 202.1 <br /> Transposer 2 PrintedlTyped Name Signature Mon'.h Day Year <br /> Z <br /> 18.Discrepancy <br /> 8@ DlscrepaucyIn&liton Space ❑ quantityyp 1 <br /> ❑T e Residue El Rejection FuII Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(c,Generate) U.S.EPA ID Number <br /> U <br /> Facila's Phone: <br /> LU 1 Sc,Signature of Alternate Facilify(or Generated Month Day Year <br /> a <br /> Z <br /> 19.Hazardous iVas e Report Management Method Cades(i.e.,codes for hazardous waste t'eatment,disposal,and recycling systems) <br /> w , 2 <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1$a <br /> Pri nted.lTypad Name A Signature a _ Month Day Year <br /> Lf�� � l <br /> SPA Form 8700-22(Rev 12-17) Previous editions are obsolete. <br /> 8 700-0.ii3 CAL40000139 S400283731 041957133 N PDO11221 SDO11221 <br />