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��l� � <br /> ER. <br /> 11 <br /> Please print or type. f Form Approved,OMB No.2050 0039 <br /> 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin Number <br /> UNIFORM HAZARDOUS �AL3F 9901 j. f 87 7} 577`2669 016 10 910 F LE <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 99 Cents Only #264 99 Gents Only#264 <br /> (209) 478-2133 1449 W March Ln 1449 W. March Lane <br /> Generator's Phone: Stockton, CA 95207-'6111 Stockton, CA 95207-6111 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Earth Specialty Waste Soiutions MNS000I10924 <br /> 7.Transporter 2 Company Name U S.EPA ID Number <br /> 8.Designated Facility Name and Site Address 21st Gentury EMN, LLC U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facility's Phone: <br /> 7755752760 NVD980895338 <br /> 9a 9b.U.S.DOT Description(includingProper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> p p pp g No. Type Quantity Wt.Nol. 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> 3 , Waste, Corrosive i1quid, aci ic, 1 DF 00045 P 791aD002 <br /> o inorganic, n. o. s. (Hydrochloric Acid, -- <br /> Phosphoric Acid) , 8, PG II, ERG#154 <br /> 3, as e, aroma a liquid <br /> s, n. o. s. 1 CF 00006 P 3311 D001 � <br /> CD (Petroleum Distillates, Alcohol), 3, PG II, <br /> ERG#128 <br /> 3. <br /> t. t0j5139ffurrlosive Rctd c- <br /> 9 <br /> 14.Special Handling Instructions and Additional Information <br /> squl c ammo e , igr_ti <br /> 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,aid are classified,packaged, <br /> marked and labeledlplacarded,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 EPA Acknowledgment of Consent. <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Signature en 5 Month Da Year <br /> a 0 _ n y Y <br /> Generator'slOfferor's Printed/Typed Name '_A� +� ^ 0711512021 <br /> ,j 16.International ShipmentsImport to U.S. ❑Export from U.S. Port of entry/exit: <br /> F- Date leaving U.S.: <br /> ? Transporter signature(for exports only): <br /> W17.Transporter Acknowledgment of Receipt of Materials Month Day Year <br /> F Transporter 1 Printed/Typed Name Signature <br /> 07 15 LO` <br /> p s f'?Y1 t P i t t m A n Month Day Year <br /> a <br /> Z Transporter 2 PrintedlTyped Name Signature <br /> a <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space � Quantity ❑Type <br /> ❑Residue ❑Partial Rejection 10IFull Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> H 18b.Alternate Facility(or Generator) <br /> J <br /> U <br /> Facility's Phone: Month Day Year <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> Z 11 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 4 <br /> 3. <br /> O 1' 2. <br /> r or operator:Certification of receipt of hazardous in covered by the manifest except as noted in Item 18a Month Day Year <br /> 20.Designated Facility Owne p Signature <br /> Printed Typed Name <br /> NATER CiL PA's e-MANIFEST SYSTEM <br /> EPA Form 870 <br /> 0-22 Rev.12-17) Previous editions are obsolete. i3E A <br /> PD071521 gD071521 <br /> 8700-2212v3 CAL40000139 S40028331 042125608 M <br />