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State of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30.99) <br />Please print or type Form designed for use on elite ( 12 -pitch) er <br />O <br />In <br />LO <br />N <br />ao <br />0 <br />O <br />O <br />ee <br />W <br />i - <br />Z <br />v <br />W <br />0 <br />Z <br />0 <br />W <br />W <br />cle <br />See Instructions on back of pogt& A_,'o�epartment of Toxic Substances Control <br />01 Sacramento, California <br />a <br />v7 <br />OPrinted/Typed <br />U <br />w <br />Ce <br />w <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUS <br />e <br />is not required by Federal law. <br />WASTE MANIFEST <br />s b- i 0 <br />of <br />3. Generators Name and Mailing Address <br />A. State Manifest Document <br />Safeway Inc. <br />23422849 <br />16900 West Schufta Road Tracy f d4 7F <br />B. Stare Generator's ID <br />4. Generator's Phone ( 209 21)33-4$(2 Burt Friggie <br />5. Transporter I Company Name 6. US EPA ID Number <br />C. 'State Transporter's IDR served.[ <br />Ecology Control Industries C 11112,1113 ® 6 a <br />D.'Tr°nsporter's Phone14 19r) 'I <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID [Reserved.) <br />F. Transporter s,Phone <br />jQ Pgsignated Focili}l Name and Site Address 10. US EPA ID Number <br />G. Store lily s ID <br />/•'r • <br />Y IIIM VCI OILGJ V�I�rrd. at1V V1�IC111 FacillL® <br />(/F�oc <br />•, V '• <br />423 Isis Ave. <br />H. Facility's Phone <br />_ _ <br />Inglewood CA 50304 Q Q 18131614 3- <br />11. US DOT Description f including Proper Shipping Nome, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />1. Waste Number <br />No. <br />T <br />AL\ el_Qfh?6 6+n -spa rrin.lc aer�mc�n �nferi <br />gVll lave\11116Ai.\!16lVlJJ •g6/J�VI JVIIV <br />State ` 1x <br />".,.�{',a <br />(O11 contaminated debris) <br />to <br />t <br />P <br />EPA/Oth'er '- <br />G <br />�® <br />1 <br />3 � a <br />NUPIt <br />E <br />State <br />N <br />b. <br />EPA/Other <br />EE <br />I <br />A <br />State :. <br />T <br />c. <br />EPA/Other - <br />O <br />R <br />d. <br />State. <br />EFA/Other <br />1: Additional Descriptions for.Materials Listed Above <br />K: Handling Codes for Wastes Listed Above <br />a. b <br />is-CNun SL -Q1 Z , n4, 05 (5 �)PCcfle#9c3n611, <br />s <br />d. <br />Sppecial Handlingg Instrudionnyy and[1dditional inforvlation <br />i'SPAnAGr Y4P!;r# ondiillG 6i7il Nili"%tiA1e, fF4¢ �dliilG �iaiifFF�0iP1li ®iFB I'1t'S !1P elAYli list®C °.S PsA LPiPiPAYBi"9'i'3t'd �i ti�tfiiiT <br />f •V\91 <br />eci <br />q 1 rI• Y,IM• 1,I• Y\\sC be 1V.M.•\ I\�• ws!\��•\V W• M\tl\.V MI M Mr111/1 M/11111M\V• <br />aMP <br />emergency telephone number (500) 32i -5479 (E :i Dispatcher) <br />EC;I _ ohiKI)AInni QC <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment ore fully and accurately described above by proper shipping name and ore classified, packed, <br />for transport by highway according to applicable international and national government regulations. <br />marked, and labeled, and are in all respects in proper condition <br />If I am a large quantity generator, I certify that I have o program in place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be economically <br />treatment, storage, or disposal currently ovailable to me which minimizes the present and future threat to human health <br />practicable and that I hove selected the practicable method of <br />and the environment; OR, if 1 am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br />available to me and that I can afford. <br />Name <br />Signature <br />Month Day Year <br />o i o <br />T <br />17. Transporter 1 cknowled ement of Recei t of Materials <br />N <br />Printed/Typed Name <br />Signature �/� //� <br />Day Year <br />month Day <br />4( <br />S <br />LCL <br />v/l. /'t <br />i <br />P <br />g <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />R <br />I <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />L <br />20. FacilityOwner or Operator Cartificotion of receipt of hazardous materials covered b th' 'est ce t as oted in Item 19. <br />I <br />T <br />Y <br />P ' !ed/Typed Nam Signature / Month Day Year i <br />O <br />�aitlwa� lost;. <br />DTSC 8022A (1/99) <br />EPA 8700-22 <br />DO NOT WRI O THIS LINE. <br />White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />To: P.O. Box 3000, Sacramento, CA 95812 <br />