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Co.see ..A..# .., a...s iC..,.., A�irinnA fnr loan nn nrdo 112.nifrMl turawrit ar 1 <br />SC. Q0494. 2241 <br />Forth A00roved. OMB No. 2050-0039 <br />EPA Fotm 8700-22 (Rev. 3-05. Ptgviars tlditiat8 otsolete." DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10264.1261 <br />UNIFORM HAZARDOUS <br />f. Generator 10 Number <br />2. Page t of <br />3. Ecanngenq Response Phone <br />4. Manifest Tracking Ntnmt <br />003235756 JJ <br />WASTE MANIFEST <br />CAL923564913 , <br />,. <br />e0o-746-7440 <br />5. Ganer"s None and Address Generators Site ' Address (d than mailing address) <br />8wMT L(%V 4SAFEWAY) <br />16900 WEST SCHUL E;RD., , <br />TRACY, CA 95377 <br />Gerund's Phone: 209-833.4938' <br />6. Transporter t Company Name U.S. EPA ID Number <br />SHOP HAZARDS SOLUTIONS- CAOOON46497 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />U.S. EPA ID Number <br />CAD980884183 <br />•11855 WHITE ROCK RD:-, <br />RANCHO C A, CA .95742,: <br />Facility's Phoone: 916-351-09® <br />9a. <br />9b• U.S. DOT Description (Including Proper Shipping Name, Hazard Clans, ID Nunes, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Cis <br />No. <br />Type <br />HM <br />and Padang Group (d any)) <br />Quantity <br />Wt.Nd. <br />1.HAZARDOUS -W-MTE SOU6. N.O.S.A. NA3077.III (LEAD0008). <br />;• 1 <br />.DWI• <br />450.. <br />,-P-- <br />.. D008 352 <br />0 <br />w <br />2.. NON-RCRA HAZARDOUS WASTE SOLID; a <br />..12 <br />: ,.DM <br />5400 <br />= -PT <br />223 • 352 <br />r, <br />NTS:8.OIL'•-• <br />3. D.,..•., , <br />.1_ ..... <br />I><IIt, <br />554 <br />G <br />223 343 <br />• •.OILY WATER'SLUDGE :� . <br />4. <br />1., , <br />:.,DMS <br />500,, <br />P. • <br />352 <br />PLIABLE GREASE <br />t4. SpecialHain i nabuoth ns and Additional Information <br />Ob/1-POLE ,700.ABSORBENTS 9BATTERYACID,';cyi. 9b/2-PRORtE#R21791;a <br />. <br />Ob/3-PROFILE #821702, - PRORLE #821793 <br />APPROPRIATE PROTECTIVE CLOTHING <br />SEE ERG #171 <br />15. GENERATOR'StOFFEROR'S CERTIFICATION: 1 hereby dedare that the contents of Oda cansigmecnt are fully and accurately, described above by the proper shipping name, and are classified, packaged, <br />marked and la placarded, and are In ad respects to proper condition for transport according to applicable Intemadonal and national gmternmental regulations.O export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to Ore terms of the attached EPAAcknowiedgment of Consent. <br />I certify that the waste mintmizatian statement ibended in 40 CFR 262.27(a) (d 1 am a large quant ty generator) or (b) (if l am a small quantity generator) is true. <br />Generatoesl yped Name MonthDay year <br />®I/ IQ <br />S <br />-a <br />tTransporter <br />16. International Shipments ❑ import to U.S ❑ ENS from U.S. Pat of entry/wit <br />signature (for exports ony): Date leaving U.S.: <br />W <br />17. Transporterkkn MedGnent of Receipt of Materials <br />� <br />T <br />NS�rnature�d�" <br />Med <br />Transporterped e re Month Da Year <br />H <br />18. Discrepancy <br />184. Discrepancy Indication Space ❑ Q.* ❑ Tps ❑ Residue ❑ Partial Re)ecdan ❑ Full Rejection <br />Manifest Reference Number: <br />1 Sb. Alternate Facility (or Generator) U.S. EPA ID Number <br />ti <br />t+a. <br />Facility. Phar: <br />18c. Sgrsbne of Alternate Fatdffiy (or ) <br />ManO► Day Year <br />QW <br />X <br />H19. <br />i azardous Waste Report Management Method Coda (i.e., obean for hazardous wasts treatment ftosal, anal recyding systerns) <br />® <br />t. <br />2. � y, <br />3. <br />4• <br />Za.Designated Facility 0. or.Operata don of receipt of covered by the manifest except as nod In stern 18a <br />Name re C D <br />EPA Fotm 8700-22 (Rev. 3-05. Ptgviars tlditiat8 otsolete." DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10264.1261 <br />