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• as <br /> Please print or type.(Form designed far use on sib i12apitch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Genandor lD Nianber 2.Pageld ;.Emergency ResponsePhore 4.Manifest Tracking Number <br /> WASTE MANIFEST CALOC103102891 900-721-2()38 005049516 JJ K <br /> 5,Generators Name and MakmgAddfees Generators Bite Address(ddigerent Than mailing address) <br /> SAFEWAY,INC cAF'EWAY#2707,0445 N PACIFIC AVE <br /> 4410 ROSEWOOD DRIVE STOCKTON,CA 95207 <br /> PLEASANT ON,CA 941;88 <br /> Generators Phone: <br /> &TransporterI Company Name U.S.EPA ID Number <br /> ENVIRONMENTAL LOGISTICS,INC CAROOO17rM78 <br /> Z Transpoder2 ComparryName U.S.EPA ID Number <br /> 8.Desgmted Fadhttyy Neme and 9laAddmss U.S.EPA ID Number <br /> FILTER RECYCLW,SERVICES. INC. - A n L sae I <br /> I W W.MONTE`AVE C,,Q.�B"4...$'. <br /> RIALTO.CA 92318 <br /> FaBitys Phone: 909-421-2012 <br /> 9a. 9b.U.S.DOT DeWpilan(McluEhg ProperShppirg Name,Hazard Class,10 Numbs, 10.Cable'am 11.T01a1 12.Unit <br /> RM and PackingGrmp(dany)) IN Type QuantityWW01. 13.Wade Codas <br /> 1. P 352 NON RCRA HAZARDOUS WASTE SOLID DM / C-u <br /> 1 J <br /> aaO <br /> C <br /> u 2 .W0N4t(3RA•hE4'lRRWUSWASfi£-MQt4ID-,.- '-Z715i <br /> 4O <br /> c- <br /> 4. <br /> . . 14.Spedal.HM.Iig inslnrr81ens'and Addinmalmforma oin <br /> 9B.1)ABSORSENi'WtFILTERS8p02120805 /21';,'� ' WEARAPPROPRIATEPPE INW62541-N <br /> 98.2)'WATERWIGAS OD2122701 One or more of the material listed on this manifest may <br /> O G 1 2 ` !v be recycled as alternative dally cover(ADC),or other <br /> methoi which uses the material In or on the land <br /> 15. GENERATOR'SfOFFEROR'BCERTIF7CATION: I hmebydeclare lhatlhe contents dUYs consignmerAarvidy and a ouratelydeacrbodaboveby the properehipphg work and nonclassified.packaged, <br /> markedand IabeleNpla®Ned,and areN all respeels Inpropertnndlion forbanspod aaardkigloappfica0lafMemallonalandnat(onalgov oNalr%Wadone.ilaxpodshipmentand I am the Primary <br /> eApoder.I ml5y0mttlle conleN9 diha mra(gmrenl cmfarm to the terms of the adedsed EPAAdmowtedgmento(Cunseot <br /> I Gerdy Uzi the waste minimization statement identified in 40 CFR 282.27(a)(dl am a large quanNy generator)or(b)(Ifl am a smallquandygeneratar)is sue. <br /> GeneratersUfftsors Pdnte4ffyped Name SignaWre j Monty Day Year <br /> X 1 ai'J G <br /> IMema"ne"I Shipment J <br /> F Import 10 U.S. ❑Export fYom U.S. Pod detmy/exit <br /> 3 Tiansparla signehae(forextends ony): Date leaving U.S.: <br /> 17.TransporlerAdmmaladginent ofReoW ofMaGalels <br /> �. T pmerl PrinWil;ped Nene Bignaturp' Month Day Year <br /> tr � is I i <br /> ZQ Tansporler2 Pdm ypad Nana Signal Month Day Yeer <br /> cc <br /> F <br /> 1&Di inpency <br /> Its.Dbuepancy lndladoq Space E] Oud Pity ❑Type OResidue ❑Full <br /> O'PaNelRejectnn� R41cs0t . <br /> Manifest Reference Number. <br /> 18b.AgareteFadly(aGaeralor) U.S.EPAID Number <br /> FILTER RECYCLING SFPVIITES' RAL TO F?)C I.)r,J FPA <br /> LL Faditys phone: <br /> r9s "' : : <br /> 18S-0a Atemate Facility(or Gene r r <br /> mlay Year <br /> AND WILL AGGI;FT TI1cS WASTE AS SHIPPED. . <br /> 19.Hazardous Waste Repod Management Method Codes{u.,toilet fornmardouawasle reahnnnl,disposal,end recong systems) <br /> 3. 4. - <br /> >�llvl <br /> 20.Casignated FadRyOwnergrOpealor.Cerp;s5i thwei tof hazardous materials 0overedbylhemeNfestm¢epi asndedin llem 18e <br /> Pdnladlyped Name 9gnelure .Month Day Yea <br /> ,� � f' 3l 7 10? <br /> FA1 Form 8700-22(Rev.3a)t Previous editions are obsolete. •'` DESIGNATED FACILITY TO GENERATOR <br />