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to pant or type, (Form 60SOW for use on elite (12 -pitch) typewraer ) <br />UNIFORM HAZARDOUS 1 Generator lD Number 2 Page 1 of I 3 Emergency Response Phone <br />—AWTE MANIFEST C .A L 0 0 0 2 8 4 4 8 3 1 1-800 24-4300 <br />S vwaou IncM s ass AD: Cllatt Generebta Site Addrees(Ifelfteal man <br />5918 ay e I Vons Safeway, Inc I Vons - 1769 <br />581E StonerCA Mall Read, Attn: Sharon Plouffe 2902 Country Club Blvd <br />Pleasanton CA 9458E I <br />3enStockton CA 95204 <br />eretors Phone: 6 2 6 <br />Trenepen I Comps y N <br />Environmental Logistics, Inc. <br />180 W. Monte Avenue <br />Bloornington CA 92318 <br />nedi sPhone: 904 421-2012 <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, H=rd Class, ID Number, <br />and packinn rmn„ ra—A. <br />Forrn Approved OMB No. <br />ng Number <br />193058 Jr <br />C A R 0 0 0 2 1 7 5 1 3 <br />C�__ <br />10. Containers <br />Nc. <br />o 'UN 175, Solids ContanIng tlamnable liquid, n.o.s. (gas/diesel), 4, 1. <br />x PGI <br />o/ <br />Type Quantity Wt'/Vo1. 13. Waste Codes <br />352 <br />i/0( -)2 P <br />3. <br />4 \� <br />14 Special Handling lneracbom and Ad d,tmmr L,In—a,.. <br />LINM75021N CNV' Y'=pER7?dNfes einiters, Hoses, Nozzles, Fuel Breakaways - 11091417 ERG*133 <br />15. GENERATOR'WFFEROR'S CERTIFICATION: I hereby declare that the mnbNs of the compnmw are fully and accurately dewsmed above by me proper shipp..g name, and are cessified, packaged, <br />marked and Iabeled(Pkacarded, and are N all respects In proper condition far transport according to applicable mtomaoonalsed national govern noeia regWalNns. Rayon shipment and I am the Primary <br />Exporter, t Cordy mat me contents of Nis consignment content N metmma of the altadw EPAAtknaadedgmem of Consent. <br />I radifyy,that the waste meemeaaon statement idenafiae in 40 CFR 29227(al (If I am a large quantity generator) or (b) (if I em a small quanfiry generator) Is We. <br />GeneraloysKlPemrs Prmkdlfyped Name Sgnatu Monty Day va <br />e m mat onN 8h ❑ <br />115 <br />r <br />LJ Import to US mm D.S. Pon of entry/exd: <br />Tryreporterslgnebxe (tor e>yais oNy): ._ <br />Date leaving U.S.: <br />17. TrensoortarANumWrMmnnl nlRw.:.r �nw..a..w _ <br />} 18, Discrepancy <br />I18a. Discrepancy IndMation Spec, ❑ Quangty <br />181a. Atlernate Facllry (or Generator) <br />J <br />U <br />LL FacdaVs Pham <br />y wm •wpun nannyamom meawe cones (re.. cables Nr hazamous waste irealmen <br />p 1 2 <br />'I 20. Desigruttod Facility , or O <br />Pnnypod Name pension: CerMrglion of receipt of hazardous meleriats covered by <br />jll <br />EPA Form 8700-22(Rev.&OS ravious editions are obseete. <br />3 <br />Residue ❑ partial Rejection ❑Full Re,ection <br />m e eptundedm o IBa <br />r [ n1�i N Oat <br />1111 <br />DESIGNATED FACILITY TO DESTINATION STATE (IF REC <br />