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Please print or type.(Form designed for use on elite(12-pNch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Goneralor ID Number2.Page 1 of 3.Emergency Response Phone 4.MaIN TrecUrg um <br /> WASTE MANIFEST c. A L 0 0 0 -,� n 0 s a , 900424-c) 1 015 492822 JJ K <br /> 5.Generetra's Name and Malling Address \• Generators S8e Adrss(it different than mailing address) <br /> Safeway Inc. Safswoy Y'4 $2707 <br /> FMaSaMrA0n 9110CMM CA 95207 <br /> Generabes Phone: - x - <br /> 6.Transporter 1 Comperry Now 1 !� U.S.EPAID Number 11 <br /> Envlrorxne W Logistics,Inc. C A R 0 0 0 :1' 1 7 5 1 3 <br /> 7.Transporter 2 Company Nam U.S.EPAID Nufter <br /> 8.Designated Parity Name and Site Addrms U.S.EPAID Number <br /> FNW Swvk*&,W. <br /> 180W UDWA <br /> Oboe*40Dn CA 92316 GAD 8 8 2 x 4 4 '' h + <br /> Fact lys Phone: 9W 421-2017 <br /> ga. 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Claes,ID Number, 10.Ganteirrers it.Taal 12.Unit <br /> HM and Padding Group Of any)) No. Type Quantity Wuvol. 13.Waste Codes <br /> I VN3176.Solft coMrabg 9lliminabb 4gdd.ifil(90VdI o11r 4.1.x FICA <br /> = 2. <br /> 3. <br /> 4. <br /> �' �,rwr N\ saw.y.:. A.r r{• reµ r. r { �.... ,,,,.A'. <br /> 14.Special Handling Insauctions and Additional Informition 1 NS)GaWD% W VA&M,HODS,Noels,Foal Brezc:. 11(191417 ERG`813.3 <br /> IKVX175276N <br /> 15. GENERATOWSIOPFEROR'S CEFMFICATiON: I hereby doctors that Bre contents of this mruignmort are fully and awvretely described above by We proper shipping name.erd are dwelled.packaged, <br /> marked and labeled/ptecamed,and are in all respects in proper oc ndition for bansport according to applicable internabonal and national govemmental regulations.I all shipmentand 1 am the Primary <br /> EVorten l ccM1Ry HA the mntenteof tdas consignment conform to the terms of the aaarhed EPAAdmoWledgrnm(of Consent. <br /> I will fhat the waste minimization statement Identified in 40 CFR 26227(x)Of I am a large quantity generator)of(b)(iII am a small quantity genal is no, <br /> Ganerafq'dO6eNrs PdMeNFyped Name 'AnaWre,� I j Monro Day ear <br /> J 16.international Shipme <br /> F ❑Importte pal U.S. ❑Eatnm U.§. PMWenary/edit <br /> t. <br /> Transporter signature(for exports only): Date lawng U.S.: <br /> ¢ 1?.TmnspaterAdmWedgmantof Rec iptofMaterws <br /> Transport r 1 PdntedRyW Name SgnaWre �— Month Day ar <br /> Q.. <br /> Tmnsporter2 rntec[Hyped arae Sgra Momh Day Year <br /> t— <br /> 18a.Discrepancy Indication Spam ❑ Quantity ❑Type ❑Residue ❑PaNal Rejection ❑Full Rejection <br /> MmafestReMence N�urMe� <br /> 18b:ARemate Facility(or Generator) FIL1�:R RECYCLING SFt VtCL�E1�PAl m <br /> a �kCAD1`+2444481 HAS THc' ^ r ,nw;i t S4fi�t 1 ; .•' <br /> Facility's Phone' <br /> W 18c.SignatumafAltemate Fadh'y(or Genembr {.,�; r�>.•'.�% —• Ml Day lesr <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Management Method Cades(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. - 3. 4. <br /> 11010 <br /> 20.Designated Fadliy,Owner or ORemtor.Certficaton of recaiptof hazardous materials covered by the mardest except as noted in Rem 180 <br /> nine ams �-s gnaMe d!�/y. }, Mont, -DaY rE;- <br /> ,. � <br /> EPA Forma -22 v 3-05) PreWous edi6bn re obsoleteATY TO GENERATOR, <br />