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01noon ndni nr hrnn <br />Form Approved. OMB No. 2050-0039 <br />EPA Fom1870U-l2 (Kev. 12-10 Previous editions are onsolete. 1JtbIV IVA I CU I'AGILI t T 1 v Cra s e-ivimimirco i a i o 1 CIYI <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />Q d 0 4 5 8 8 4 <br />12. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />0.3702526 FLE - <br />WASTE MANIFEST <br />C A L 0 <br />1 <br />(800) 484-9- O <br />5. Generators Name and Mailing Address Generator's Site Addresspf different. than mailing address) <br />Quik 9tor ilarkets, Inc- #039 <br />Quik Stop Markets, Inc- <br />4567 Enterprise Street 22B5 E Fremont 5t. <br />Fremont, CA 94538 Stockton, CA 95..-`''-05 <br />Generator's Phone: (5117) 448-2.28- <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />BEL9HIRE CARD 0 018 3 9 . 3 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Del -len o Kerdoon C A T Q Q O O 13 3 5 2 <br />2000 !V. Alameda Bt <br />Compton, CA 90222 <br />Facility's Phone: (310) 537-7100 <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11, Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (ii any)) <br />Quantity <br />Wl.lvol. <br />1' Citd1203, Ga-zoli.ne Mikture, 3, PG 11 <br />G <br />124 <br />z <br />2. <br />w <br />0 <br />3. <br />4. <br />14, Special Handling Instructions and Additional Information DEAR ALL APPROPIUATE EESIe 31Q138 u� <br />ERGO: 128 PERSONAL PROTECTIVE QUIIC3`rOP CCN- 6592u1 81C <br />Gazoline & Water CLOTHING. <br />uri <br />15. GENERATOR'SIOFFEROR'S 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 labeledfplacarded, 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 Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenl of Consent. <br />I certify that the waste minimization statement identified in 40 FR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quant' nerator) is true. <br />Generators/Off is Printed/Typed Name Signature Month Day Year <br />l <br />;r„: <br />16.Inte on h menu <br />❑ Import to U.S. ❑ Export from U.S. Port of enby/exit• <br />K <br />Transporter signature (for exports only): Dale leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Pdntedrryped, a (� r Signature r Month . Day Year <br />n0. <br />i <br />'1 <br />Transporter 2 Print ad Name Signature Month Day Year <br />h <br />18. Discrepancy <br />18a. Discrepancy Indication Space D Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number, r,r <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />U <br />Facilitys Phone: <br />18c. Signature of Aitemate Facility (or Generator) <br />Month Day Year <br />Cn <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />W2. <br />2. 3. <br />4. <br />Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/iyped Name Yom. Signature Month Day Year <br />• i �"� � � <br />EPA Fom1870U-l2 (Kev. 12-10 Previous editions are onsolete. 1JtbIV IVA I CU I'AGILI t T 1 v Cra s e-ivimimirco i a i o 1 CIYI <br />