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Please print or type.(Form designed for use on 218(72-pitch)typawrilec) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 d 3.Emergency eaponse PRone 4.ffa—nTrW Tracking Number <br /> WASTE MANIFEST CAL000280768 1 1-800 24-9300 013863732 JJ K <br /> S.Generators Name and MailingAodress afeway nc./VOns Generator's Site Address(itdAferent than mailing address) <br /> 5918 Stoneridge Mall Road Attn:Sharon Ploufa Safeway Fuel#2707 <br /> Pleasanton,CA 94588 6425 North Pacific Avenue <br /> Ganeatoesphana: 626-821-6192 Stockton, CA 95207 <br /> 6,Transporter'1 Company Name U.S.EPA ID Number <br /> Environmental Logistics, Inc. CAR 7241930 <br /> 7.Transporter Company me .si. PAIDNun6er <br /> 8.Designated Fe Ry Name and Site Address US.EPA ID Number <br /> Hazmat, Inc. <br /> 6300 Stadium Drive, Kansas City, MO 64129 <br /> Fadlltys Phone: 816-924.6884 MODW 1123391 <br /> lie. gb.U.S.DOT Description(including Proper Shipping Nam,Hazard Class,ID Number, 10.Contal l 11,Total 12.UnitFIM and Packing Group(If any)) Na. Type OuanBty WtNo1, 13.Waste Codas <br /> o T UN1993,Waste flammable liquid,nos(gasoline) D001 D018 343 <br /> x ` ' 3?PG It ?I: ' DIM , 25 P, <br /> z 2 <br /> w <br /> 3. <br /> 4. <br /> 14.SpecialHandling ImbrociloodsardAckifflonal Incartarthan Emergency Response CHEM1 0 24- 3 C <br /> 9b1)Profile# AES-62742 ERG#128 1 x 10 <br /> Rejected from manifest#013481366JJK <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by die proper shipping name,and are classified,packaged, <br /> marked and labeleWplacarded,and are in all respects in proper condition for transport according to applicable internationalwA nations]governmental regulators.R export shipment and I am the Primary <br /> Exporter,I cerdfy,that the comers of this consignment conform to the tress of the attached EPAA.cknowiedgmentof Consent. <br /> I certify had the waste minimization statement Identified In 40 CFR 262.27(a)(111 sm a large quantity generator)or(b)(Ill am a smell quantity generator)Is hue. - <br /> Generstn'slOReroes Printed?yped Nene Signaftme Man Da Year <br /> Steven Masters,offeror ,A' T �/ ig <br /> F 6.Ins a Shipments L1 import to U.S. ❑Export hoes U.S. Pad of mtrywt <br /> Transporter signature(for exports only): Date saving U.S.: <br /> K 17.1 nspatsrAdmowleedgment at Receipt of Materials <br /> Tm r 1 Print Name' .r - � IgnaNre <br /> Ge, <br /> . .Mon .Dpy YearGe, a <br /> QTranymner2 n e signature Month Day Year <br /> ♦ 18.Discrepancy <br /> 19a.Discrepancy indication Space <br /> Quantity Type Residue ❑Pargal Relectlon ❑full Rejection <br /> Manifest Reference Number. <br /> 18b.Ahemats Faci ty(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Fadllys Phone: <br /> Igo.Silgrotura,of Alternate Facility tarGenerator) - Month Ua;v Year. <br /> N19.Hazardous Wass Report Management Method Codes(I.a.,codes for hares lous waste heatmem,disposal.and recycling systems) <br /> C 1. / 2. 3. 4. <br /> 20,Designated— <br /> FacgYy Dvmar r Operator,Certification of receipt of hazardous materials covered by the manifest t nosd'm Item l8a <br /> 1eme� { <br /> l 1 ""' on y., Yew <br /> EPAFann8700-22(Rev.3-05) PreviouseedNonsare obsolete. DESIGNATED FACILITY TOGENI-/E,+RATOF <br />