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State of ColiFornio—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9.30-99) See Instructions on back of paDepartment of Toxic Substances Control <br />Please print or type. Form designed for use on elite 112 -pitch) iter. r Sacramento, California <br />O <br />W) <br />h <br />t\ <br />fV <br />h <br />m <br />O <br />O <br />V --q <br />OJ <br />U <br />r,— Z <br />Cle <br />Loo <br />CMI U <br />Z <br />I t— <br />N <br />O <br />00 <br />O <br />et <br />N <br />O <br />O <br />m <br />9X <br />Ujt- <br />Z <br />w <br />U <br />w <br />rn <br />O <br />N <br />w <br />Ix <br />Q <br />Z <br />O <br />Q <br />Z <br />LU <br />Q <br />U <br />y <br />•a <br />U <br />Z <br />DTSC 8022A (1/99) <br />EPA 8700-22 <br />DO NOT VhITE BELOji THIS LINE. <br />anidalid'y'efei:. 'aeeecvysay oEee.1. <br />White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />To: P.O. Box 3000, Sacramento, CA 95812 <br />L <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 j Information in the shaded areas <br />UNIFORM HAZARDOUS <br />is not required by Federal law. <br />WASTE MANIFEST <br />•L w [ � n m <br />of 7 <br />3. Gererotor's Name and Mailing Address <br />A. State Manifest Document Number . <br />Safeway Inc. <br />23571001* <br />16900 West Schulte Road Tr3Cv r-.aaK'A77 <br />B. State Generator's ID <br />4. Generator's Phone ( (209) 833-4939 Vouq Heath <br />5. Transporter 1 Company Nome 6. US EPA ID Number <br />C. State Transporter's ID [Reserved.]. <br />Ecology Control industriesD. <br />0, a 3' <br />Transporter's Phone <br />51 n,.*n -j;.1 Ao <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID [Reserved.] <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />as,olsv. c.,macias <br />e nne}I vice •wca vLle s.. -e seeaw-V acne a us.neLg <br />425 iris Ave. <br />H facility's Phone <br />InglewoodCA sa3a9 - - - - - - - - Al- <br />If <br />- - -- - _ - - - - <br />11. US DOT Description (including12. <br />Proper Shipping Name, Hazard Class, and ID Number) <br />Containers <br />13. Total 14. Unit <br />Quantity Wt/Vol <br />I. Waste Number .. <br />No. <br />I Type <br />f"Lnirne-ieln cniin2c n n o ICeel�e erin �nini ®I�e nrl�.a n{\ Q <br />State <br />V VeIVVIeI VVVe1VJ' Ie.V.V.\Ll Vr1 YIeV I1V/Vr IfVVVee./41eLlt Vi <br />•r <br />EPA/Other <br />G <br />UN 1 IbU, Ki 11 <br />N <br />NA.RC:REi ha7arcin:j% wasfip, finlit^llfE7il, FInnr swPPniE <br />State <br />01015 <br />�V <br />35' <br />EPA/Other <br />A <br />State <br />T <br />c. <br />O <br />EPA/Other <br />R <br />d. <br />State <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />ia. Drum # Proflle #90067 - <br />K. Handling Codes For Wastes <br />a. [� <br />listed Above j <br />b. 6 /{ <br />i 1 b. Drum # 5 Profile #900700 <br />c. <br />d. _. <br />i <br />15. Special Handling Instructions and Additional Information <br />Wdamar nrerenar nrntar+titim amiiviimant w1iHim hawnr,�.eiinn 9elSitmirsts;ta nr ronle�tm4&a am aviinrewima4a, ?d Lin�aa <br />I--r..e r•,,.,...........�.•.r......... ..�. ...Ve..., rr• <br />emergency teiephone number (800) 32z -5479 (i:ci Dispatcher). <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 are classified, pocked, <br />marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and nalionol government regulations. <br />IF 1 am a large quantity generator, 1 certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economical] <br />and that I hove selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health <br />practicable <br />and the environment; OR, if I am a small quantity generator, I hove 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 />Printed/T ped Name <br />Signature <br />Month Day Year <br />s <br />t <br />T <br />17. Trans orter 1 Acknowildgetfent of RecApt of Moterals <br />R <br />N <br />p m Sin nj� Year <br />S <br />P <br />0 <br />(S, j1 <br />18. Transporter2 Acknow d emenr of Receipt of Materols <br />A <br />Printed/Typed Nome <br />Signallfvt <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />n <br />I <br />L <br />1 <br />20. Fo/ilik Owner or operator Certification of receipt of hazardous materials covered by his ifest except oted in 11 19. <br />T <br />Y� <br />print / <br />Signal ure <br />Month Day Year <br />D 614 <br />DTSC 8022A (1/99) <br />EPA 8700-22 <br />DO NOT VhITE BELOji THIS LINE. <br />anidalid'y'efei:. 'aeeecvysay oEee.1. <br />White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />To: P.O. Box 3000, Sacramento, CA 95812 <br />L <br />