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- 1 <br /> Please print or type.(Farm designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.GenemPeg <br /> lar lD Number 2. elol 3.Emergency Response Phone 4.manifest TmMail Number <br /> WASTE MANIFEST CAL 003'10259 1 900-721-2tM 1 0 0 4 18 10893 0 9 JJ K <br /> S Genemtoes Name and Mailing Address Generators Site Address i f different than mailing address) <br /> SAFEWAY,INC SAFEWAY A 17011,0445 N PACIFIC AVE. <br /> 4410 ROSEWO00 DRIVE STOCKTON.CA 85207 <br /> PLEA3ANTON,CA D4588 <br /> Generetm's Phone: :70 <br /> e.Tmnsportert Company Name U.S.EFAIDNumber <br /> F_NVIRONMEWAL LOGISTICS,INC I CAR000172478 <br /> 7.TTranssp�oorrterrF2.flCompany NNa�meeSltepd�sso U.S.FPAID Number <br /> S* FIL'TF_iiR VCLINa Sf'%WCES, INC. U.S.EPA ID Number <br /> r^.BnOM>4A AA1 <br /> 180 W.MONTF AVE "•"""`'''"" <br /> RIALTO.GA ti12316 <br /> Facatys Phore: 909-421-2012 <br /> ga 9b.US.DOT Description Qnduding Proper SNpping Name,Hazard Class,ID Number, 1D.can tektem 11.Tatal V.unit 13.Waste Codes <br /> HM and Peckkg GmW((emh) No. Type Quantity WtNal. <br /> O 1. NC.1N RCRA 1.1A7.ARDOUS WASTE SOI.ID 1 CM -•7 P 352 <br /> t <br /> z 2. FF9P1•RC"is7MdP A�F}96ldFrW.4S'T-k46Pdi0 bkl t3-—434. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling IreWdimm andAdditional Infommllon <br /> 8.8'I/A13SORRENT'JVJFII.TERS 0021200nsi f y 5 ) VI iAR APPROPRIATE PPE s ' ' INV$4703(5 <br /> ea iytaxaE+ral7ASAsswase4 <br /> 15. GF.NERATOR'MFFEROR'SCERTIFICATION: I herebydedare that the contents of tido mrefgnmenl are fully and scamtay dawAbed above by the proper shipping name,wd Adadaesfied,packaged, <br /> marked and lab"placarded,and are In all respects In proper coreflonfor transport aaanflng to epplicableintemalbnal ant nal govemmental regulations.Ifexport shlpmerd and am the Prouny <br /> Exporter,I certify hal the contents dgds censigenentcanform b gm terms of Na ahached EPAAcknowledgmant ofConsam. <br /> I cagy lha t e vale minimization statemeclidentifled in 40 CFR 26227(a)of l am a tergegcontiygenmatarj or(b)Off am a smal quengy generator)issue. <br /> (�YMmes Printedflyped Name_ -.-�++ -v— �"^�....� Mon" 0Y Year <br /> 18.Inkrtmtional5hprents ❑Impmtto US. ❑Expodfrom U.S. Portolenbylexib <br /> Transpormr sigmas(far exports only): Dant karing U.S.: <br /> Oc 17.TrenspaderAdrasledgment ofRecelptof Ittals 1 <br /> Tpoler 7 Pdatedffyped N _ re Mon ' Pay yl <br /> ay <br /> qti, r �� Sign (.L-A <br /> Z Transporter 2 Prat yped Name Stipmatuffe Mon" Day Year <br /> K <br /> 1 19.Dkerepaney <br /> I 18a.DlscrepamymNcalbn Space ❑ quantity 1:1 Type El Residue ❑Pastel Rejection ❑Full Refection <br /> ManlfamReference Number. <br /> 186.Allemate FadWy(arGe:w.rabr) _ U.&EPA IR Nun"eL <br /> -1r, (:_ , " . . j"lrtir <br /> r91ee 51gnalureAAlkmate Faclay(Of Gsm"har) AND OLL A0UE-'I 11'1�JrvVA15 l= As veil ::.L). Mon" Day Year <br /> Fz <br /> y19.Hazardous Wale Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling syslame) <br /> 1. 2 3, 4. <br /> 20.DesgnaGed Fm4kyOwma orr".Cedifsagorofreraiptalhazardaus materials covered by the manifest except as aded In Ilam lie <br /> Prirdedfryped Name _.. !/f Stgrelure _ McnilDay Year <br /> ar <br /> EPA Form 8700-22(Rev.3-OS) re obsolete. DESIGNATED FACILITY TO GENERATOR <br />