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J1211111111111111111 Please print or type. Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAL000369901 1 (877) 577-2669 014403159 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) 99 Cents Only #264 99 Cents Only#264 (209) 478-2133 1449 W March Ln 1449 W. March Lane Generators Phone: Stockton. CA 95207-6111 Stockton, CA 95207-6111 6.Transporter 1 Company Name U.S.EPA ID Number Stericycle Specialty Waste Solutions Inc MNS000II0924 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address 21st Century EMN, LLC U.S.EPA ID Number 2095 Newlands Dr. East Fernley, NV 89408 Facility's Phone: 9a 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. X 1' LIN1993. Waste. Flammable liquids. n. o. s. 1 DF 00099 P 33 1)100� o (Petroleum Distillates, Alcohol), 3. PG II. ERG#128 W X 2 LIN2811. Waste Toxic solids. oroanic. n. o. s. 1 CF 0002 P 33� D00 D01 0 (Pvrethroids). 6. 1. PG II. ERG#154 3. 4. � 4 14.Special Handling Instructions and Additional Information 1. 101992(F 1 as a a b l e Liquids) 2. 101985(Toxic Solids) 15. GEN ERATOR'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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or( (ifI am a small qu tity generator)is true. Generator's1O or's Printed/Typed Naml Signature n Beh f 99 Cents On l V Month Day Year 0 2T 20 0 j 16. lernational Shipmenj IL- _]Imp to U.S. ❑Export from .S. Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: at 17.Transporter Acknowledgment of Receipt of Materials LU Transporter 1 Printed/Typed Name Signature Month Day Year a Johnnv Harper 0 2 20 0 z Transporter 2 Printed/Typed Name Sign re Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Partial Re ❑ I ❑Residue Rejection Full Rejection Manifest Reference Number: 181b.Alternate Facility(or Generator) U.S.EPA ID Number U LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z N19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1. 2. 3. 4. rl /4/ 14 /`t- l 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed NameSignature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM 8700-2212v3 CAL40000139 S40028331 041758005 M PD042720 SD042720