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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST I C A L 0 0 0 0 4 5 8 9 9 1 (800) 424-9300 016572911 F L E 5.Generator's Name and Mailing Address GGenerators Site Address(if different than mailing address) Quik Stop Markets, Inc. 1030 stoglivekets, inC. #076 165 Flanders Road Stockton, CA 9ve. Westborough, MA 01581 5215 Generators Phone: (5,101 44.5-22921 6.Transporter 1 Company Name U.S.EPA ID Number BELSHIRE C A R 0 0 018 3 913 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number U.S. Ecology, Nevada Operations N V T 3 3 0 0 1 0 0 0 0 Highway 95, 11 miles S. of Beatty FScI tysP off, NV 89.003 (775) 553-2203 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10,Conlainers 11.Total 12,Unit HM and Packing Group(if any)) No. Type Quantity Wt Nol. 13Waste Codes . 1' Pon—RCRA Hazardous Waste, Solid (ERG #171) P 352 *0018; O (Rags, absorbent, & debris impacted with petroleum hydrocarbons) Z 2. 1 3 4. 14.Special Handling Instructions and Additional Information WEAR ALL APPROPRIATE 'REST : 3 3 4 2 8 3 Generator is a RCRA VSQG as defined in PERSONAL PROTECTIVE 40 CER 260.10. D018 code represents CLOTHING. QUIKSTOP CCN: 659237 waste that is RCRA identified but not PROFILE # 07021427-0 RCRA regulated. 5 - 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by[he proper shipping name,and are classified,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If expod shipment and I am the Primary Exporter,I certify[hal the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization lement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)IN I am a small quantity generator)is true. Generaloes/OHerors P ted/Typed N Signature Monlh Day Year GJ "ED A-11At OL 101 1 2--'3 16.International Shipments ❑Import to U.S. Export from U.S. Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LU Transporter 1 ted/Typed Name Signature Month Day Year a iY4- 7-3 IZI z Transporter 2 Printedrryped Name Signature Month Day Year r- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U rai Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z v519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Prinledrryped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM