Laserfiche WebLink
:ase print or type. Form designed for use on elite <br />UNIFORM HAZARDOUS 1. Generator ID Numl <br />WASTE MANIFEST <br />S. Generator's Name and Malting Address <br />Quik Stop Markets, Inc. <br />4567 Enterprise Street <br />Fremont, CA 94538 <br />Generator's Phone: <br />6. Transporter 1 Company ame <br />BELSHI RE <br />12. Page 1 of 1 3. Emergency Response Phone <br />CAL000045936 1 (800) 424-9300 <br />Generator's Site Address (f different the <br />Quik Stop Markets I <br />205 W Lockefiard tet. <br />(510) 445-2282Lodir CA $5241) <br />Form Approved. OMB No. 2050-0039 <br />7"1Mber <br />1824 FLE <br />CAROOD183919 <br />C.lerylenno ISeraacln <br />2000 N. Alameda St. CATOOOD1335.2 <br />Compton, CA 50222 (310) 537-7100 <br />Faality's Prone: <br />ga. 9b. U.S. DOT Description Including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codas <br />Hkj and Packing Group (d any)) No. Type Quantity Wtivol. <br />x 1. UN1203, Gasoline Mixture, 3, PG II 134 <br />A- lit \ I -A & <br />14perialHe'Instructions WEAR ALL APPROPRIATE CyC+�I:G-1VZt] I <br />�1 TOP CCN: <br />Gasoline <br />. & Water PROTECTIVE CLOTHING. 65937 <br />1X5 <br />15. GENERATOR'SJOFFEROWS CERTIFICATION: i hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are In all respects In proper condition for transport according to applicable International and national governmental regulations. if export shipment and I am the Pimary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknaMedgment of Consent <br />Ice* that the waste minimization statement Identified In 40 CFR 262.27(a) (d l am a large quantitygenerator) or (b) (if I am a smelt quantity, generator) is true. <br />Generator + rots FrintedlTyped Name gna re n ay, <br />.Y i I i 1 _ 10 1 t eo I <br />17 <br />❑ Import to U.S. <br />Export from U,S. <br />V, <br />`'i 1141- l <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Futi Rejection <br />Manifest Reference Number. <br />M. AKemale Facility (or Generator) U.S. EPA ID Number <br />J <br />i. 21 —Mtu'c Phnna- <br />19. Hazardous Waste Report Management Method Codes (i.e., cedes for hazardous waste treatment, disposal, and reWarg systems) I <br />Designated Facility Ownar or Operator, Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br />dedryped Name Signature Month Day Year <br />m 8700.22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />