Laserfiche WebLink
$•Generat0r's Name and Mailing Address _ y T tvv ��t ^ate... <br /> QUI-k Stop Markets, Inc. Generator'sSttoAddress(it different thanmallingaddress7140 <br /> 165 �u} rktetli Inc. <br /> FZatiders Road 2011 li .Lock• ord 3 <br /> �stborautgh, NA 01581 Lodi, CA 340 <br /> Generafor's Phone: �Slp} ��rJ_2282 <br /> 6-Transporter 1 Company Name U.S.SPA ID Number <br /> ULSHIj E Cift 0 0 o 19 3 913 <br /> 7.T anspoder 2 Company Name U.S-EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> World oil Rea cling C!=0 I 0 0 i 3 3 5 2 <br /> 2000 N. Al,��d. 5t. <br /> Cyton, CA 90222 {31fl} 537-?ifla <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. Type puanlity WIND,. <br /> UN1203, Gas%line Mixture, 3, Ill IT G 19+! <br /> w 1 � ] <br /> a p. <br /> W <br /> 3. <br /> 4. <br /> f <br /> f i A <br /> 14.Special Handling Instruclions and Additional Information ll ALL APPR Willis BE I: .7 71 <br /> iIAG#; 1 <br /> 6saoif -:fs Water gCLMIAG,� $GTI. +QUIRSTOP Cll 659237 <br /> 1l. 13ENERATDRVDFFEROR'5 CERTIFICAMON:I hereby declare that the contents of this consignment are fully and accdrately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlpiacarded,and are in all respects in proper condition for transport according to applicable international and na€tonal governmental regulations.It export shipment and I am the Primary <br /> Exporter.I x*that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Corenf. <br /> f certify that the waste minimization statement identfied in 40 CFR 262.27(a)(if I am a large quantity generator)or(b}(if I err a small quantity generator)is true. <br /> Generator'slOHeror's Prirril lfyped Name Signature Month Day Year <br /> J 16.Intemat onal Shipments t <br /> F ❑Impod tc U.S. ❑Export from U.S. Port of enlrylexit: <br /> z Transporter signature(for exports only), Date leaving U S.- <br /> 17.TranspoderAc*nowledgmenl of Receipt of Materials <br /> Transpo er f Pantedd Name Signature <br /> Month Day Year <br /> tz <br /> aTransporter2PrintedfTyped Name Signature <br /> r� Month Day Year <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type yp ❑Residua ❑Partial Rejection ❑Full Rejection <br /> Manifest Reierence Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> 4? <br /> LL. Faclity's Phone: <br /> LO 18c.Signalare ofAltemate Facility(or Generator) <br /> IVonfn Day Year <br /> 4 <br /> z <br /> 19.Hazardous Waste Report Management Method Cotler(i-e„codes for hazardous waste treatment,disposal,and recycling systems) <br /> n 1. 2. 3.-.. 4- <br /> 20,Designated Facitily Owner or Operator,Certification of receipt of hazardous materials covered by the manifest except as rail in Item 1 Be <br /> PrinlsdlTyped Name SignaNre <br /> Month Day Year <br />