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Form Approved.OMB No.3050-0039 <br /> Pleag@pr>r�tgSrJ9pe.(Form designed for use5n site(12-pitch) liter.) ' <br /> UNIFORM HAZARDOUS 1'Genealarl Number 2.Pagel of 1 3.Emergency Response Phone 4.Manifest Tracking Number <br /> JJK' <br /> WASTE MANIFEST C A L 0 0 © 2 8 0 7 .6 8 1 800.424-9300 7 y <br /> 5. n mors N e and Mailing Address GeraraWs Site f dMemm than mailing address) <br /> away nc. Safeway Fuel V707 .'+. <br /> 6918 Sbnef alp Mall Road 6425 N Pacific Ave- <br /> Pkesanbn CA 94588 S*-kion CA 95207 <br /> Generators Phone: 9 2 5 4 6 7 - 3 0 0 0 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> �mifQ11I1ron1a1 kogisNDS. Inc c.a R 0 0 0 <br /> 7.Tmnepo11er2 ny me" - - U.S.EPA ID Number -. - <br /> 8 WIA Facyc Nam and Site*P&S,Inc U.S.EPA ID Number <br /> Irc "180 W.Mage Avenue <br /> Bloordrrgbn CA 92316 <br /> Facilitys Phone: 908 421.2017 ICAD982444481 <br /> ga, 6b,U.S.p0T Deswlpton(nduft Pmper.Stepping Name.Hazard Class,ID Number 10.Contxinem 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Paddng Group(rf anY)I No. Type Duantlty WtNd. <br /> 4"175.'sogds cwNeNwg flarnmkols*W,n.o.s 352 <br /> yo .x 4.1 PGII -- — - <br /> 2. <br /> FF <br /> 14.SpeciAl Handling Instructions and Additional Informa0m 1 NS)Gas/Diesel Malls,HOSGS,NossNs,Fuel Breakaways-11091417 ERGi1333 <br /> fi4{/5188119N <br /> 15. GENERATOR'S(OFFEROR'S CERTIFICATION: I hereby declare tlrat the contents of this consignment are fully and aaurately described above by the proper shipping name,and are classified,packaged, <br /> marked and hiheledlplaoarded,and are in all respects n proper cond'Non for transport according to applicable International and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I batty that the comers of this consignment conform to the terms of are attached EPAAclmowledgment of Consent. <br /> I cenily that the mats mirimtration statement identified in 40 CFR 26227(a)NI am a large quantity generator)or(b)(HI am a small q generator)is bue. <br /> Gene7slORtemes Pdntedlfyped Name Signature Month Day Year <br /> i <br /> 6.nleme npmeM ❑ <br /> s . <br /> F J import to U.S. Export'from U.S. Portafentry/exib <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.TraraporterAdarmledgrrxnl of Receipt of Materials <br /> Tm PnftdffyW Name Month D Year <br /> i, <br /> Gsponer n Name Signature ,- Month Day lilear <br /> 16.Discrepancy <br /> ]aa.Dlsempency Indicalbn Spate ❑ Quantity, El Type El Residue ❑PadWR*or a Foil Relaellon <br /> r n <br /> 1ab.aWn8e dty(orCabfvlD , S F01� U.S.Em IVmrmber <br /> FILTER FIECYCLING SERV PRpPRfATE PERMIT( ) <br /> LL FadfityBPane' 0982444481 HAS�k;AE STA AS SHIPPED. <br /> gnaWreo Alternate amdy or Month Day Year <br /> R <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codas far hazardous wawa naonem,disposal,and'recyding,sysMms) <br /> G 1. 2. 3. 4. <br /> 20.Designated Facility carrier or r:Certification of receipt of hazardous materials covered by the manes a pt as mled n 16a <br /> VIII' yped mar- g 11 nlcnT Dal. yea! . <br /> EPA Form 8700.22(Rev.3-05) Previous dollionsraio ninsole DESIGNATED FACILITY TO GENER TOR <br />