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Please print or We.(Form designed foruse on ellle:(12•pitch)typewriter.) For i Approved.OMB No.20500039 <br /> UNIFORW'HAZARDOU 1.Generator ID Number ?Page t of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CALW0310269 I 909.721.20.&8 004250924 JJK <br /> 5.Generators Name and Malwg Address Generators Site Address(if d f erent Than mailing address) <br /> SAFEWAY,INC SAFEWAY 2707,6445 N PACIFICAVE <br /> 4410 ROSEWOOD DRIVP% STOCKTON,CA 95207 <br /> PLEASANTON.CA L45B8 <br /> Generators Phone: 7• <br /> 6.Transponerl CompanyNmne U.S.EPA IO Number <br /> ENVIRONMEINITAL LOGISTICS. INC CAR0001724713 <br /> 7.Transporter Company Name U.S.EPAID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> FILTER REOYCLING SERVICES.INC. CAU982444481 <br /> 180 W.MONTE AVE <br /> RIALTO.CA 02316 <br /> FaagYG Phone: 909-421-2012 <br /> go, 9b.U.S.DOT Desoription(Indudng PmperBNpping Nam%Hazard Close,ID Numbs, 10.Conho rs It.Taut 12.Unit U.Waste Carer <br /> .HM and Packing Group(ilmry)) No. Type OnanNy WINbl. <br /> cd 1' NON RCRA HAZARDOUS WAST[SOLID .2DM � CSO P 352 <br /> w 2. WON RCRA HAZARDOUS WASTE LIQUID .2 UM ((}r G •134 <br /> cD <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 9.BI"SORBE:NT WfFILI'ERS#02'i208OS 1-D! c, WEAR APPROPRIATE PPE IMV#4?376 <br /> 9B2)WATERWIGASWO2122701 .Z>' e" One Orinbre.ltf the rnpteri 1. cte 4n'thi manifegCmay <br /> be reiyglWas altfirnative at-liver((ADE) or other <br /> =h'C,d whlth_uses the;rYleterlal in 3r'on R9 fan& <br /> 15. GENERATOR'Sif)"EROR'S CERTIFICATION:I hereby declare Net the mnlenls ofthfa mrsignmentarefully and acamtelydeacdbed above bylhe propershipphg nem%and am classified,Packaged, <br /> marked and laheled oacerded,and are mall respects In propercoolditlon for harepaitaccordng to applicable lntemalbrelard national governmental regulations.If uponshlpment and 1 am Na PftW <br /> FVmter,l certify that the commnis of this consgnmenlconform to the terns ofthe efached EPAAcknWedgmentaf Commit. <br /> I retf4ythat the waste minimization statement ilendged In 40 CFR 26227(a)OfI am a large quantity generator)or(b)Off am a small quantity generator)is he. <br /> GenemlV406em1s Pdntafryped Name Sg,ml,Ae\ ,' ,, Month Day Year <br /> It International Shipments El <br /> F krryad WU.S. ❑Fxpan from U.S. Pod of anlryledC <br /> Trampmersignahae(for aaporls only): Dabs leaft UA: <br /> W 17.TranspcderAebroModgment ofReo*ofMotorists <br /> Tmrmoder frMeMypall Signatua , Month `Day Year <br /> dLj <br /> QToonsporler2lProemr. sore ` SlgnaWre' a Month Day Year <br /> fY <br /> F <br /> 1B.Dlscrepancy <br /> 18%0iscrepancy Indication Space ❑chmiry ❑Type ❑Resklue. j ❑FulR <br /> ElPertiel Re aclkln eJacfion <br /> ManUt Reference Number. <br /> 18b.Alternate Facility(or Genembrj __. _.._ .- _ .. U.S.EPAIO Number <br /> Zi <br /> aap+. Fadilys Phone: FILTER <br /> rard ISo.Signature of Alternate FaaV(or Generator) ••J t o^s>C i r t':j !f•..::. ,::. ..r•; t:1'pi..'4 o tC i ._�.;l;I pa) Year <br /> hY <br /> AND WiLLA00&--i" irii5 .. "i- = - <br /> y19.Hazardous Waste Report ManagemamMeNod Codes(i.a,codesfor hazardopg waste treatment,disposal,and recycling systems) <br /> � 1. 2 I 3. - 4. , <br /> 20.Designated FadRyOwnerorOp Ia:CeMcetlmtoframotofheaerdousmaWWs memo by Nemadfestemptasnded In Item 18a <br /> yll tetlllyped Nemo Signature Monty Day hepar <br /> EPA Form 8700.22(Rev.3-05) Pr viouaedillamobaate(e. IDESIGNATED FACILITYTO GENERATOR <br />