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III�III�III�II�III�IIII�IIIIIII�IIIIIIII�IIINIIIIIIIIII�I Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number WASTE MANIFEST CAL000369835 1 (877) 577-2669 014403067 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) 99 Cents Onlv #157 99 Cents Only#157 (209) 339-9103 300 W Kettleman Ln 300 W. Kettleman Lane Generator's Phone: Lodi. CA 95240-5740 Lodi. CA 95240-5740 6.Transporter 1 Company Name U.S.EPA ID Number Stericvcle Specialty Waste Solutions Inc MNS000110924 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address 21st C ent ury EMN. LLC U.S.EPA ID Number 2095 Newlands Dr. East Fernlev, NV 89408 Facility's Phone: 7755752760 NVD980895338 ga 9b.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. LIN2811. Waste Toxic solids, organic, n. o. s. 1 DF 00075 P 33 DO01 D01 o (Pyrethroids). 6. 1. PG II. ERG#154 Z A2. 1JINlY13. Waste. Flammable liquids. n. o. s. 1 CF 00014 P 3311 D00 LU (Petroleum Distillates. Alcohol). 3. PG II. - - -•,.-- ° - ERG#128 X 3. LIN2810. Waste Toxic. liouids. organic. n. o. s. 1 CF 00024 P 33k DOI (2.4-D. Pvrethroids). 6. 1. PG II. ERG#153 _..,._,. n..... ............. 4. 14.Special Handling Instructions and Additional Information 1. 101985(Toxic Solids) 2. 101992(F 1 a m ma b 1 e L i o u i d s) 3. 101986(Toxic Liouids) 15. GENERATOR'S/OFFEROR'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(b)(if I am a small quantity generator)is true. Gen eral 'sl eror's Printed Type ame Signature eha 1 99 Cents On l v Month Day Year 04 04 2020 16.International Shipme is ❑ port to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: OC 17,Transporter Acknowledgment of Receipt of Materials I- Transporter 1 Printed/Typed Name Signature Month Day Year a Johnnv Harper 0 0 Leon Z Transporter 2 Printed/Typed Name Signature t VMonth Day Year F- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U rai Facility's Phone: LU 18c.Signature of Alternate Facility(or Generator) Month Day Year ZZ 12 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) �/ 0 1. p� � TflT 3' 20.Designated Facility Owner/oorr Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed NameL � Signature � p � Month Day Year kiln G; 2 �.► t=om f/�-t� V )s )ill EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM 8700-2212v3 CAL40000139 S40028246 041730530 M PD040320 0040320