Laserfiche WebLink
f <br /> Please print or type. <br /> Form Approved.OMB No,2050.0038 <br /> P YP ,�� PP <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3•Emergency Response one 4. an t Tracking umber <br /> WASTE MANIFEST 1 (800) 424-9300 1017544111 FLE <br /> 5•Generator's Name and Melling Address Generator's Site Address(If different then moiling address) <br /> Quik Stop Markets, 2nc. - �i�k Stop Markets, Inc. #132 <br /> 165 Flandera Road 3555 V. Haqmr Ln. <br /> l augh, KA 01581 Stockton, CA 95219 <br /> 6.Transporter 1 Company Name U.S,EPA ID Number <br /> BELSHIRE C JL*a 0 0 1 a 3 9 1 <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 /> World Oilclip i'Recy q C�TO ® 001335Z <br /> 2000 N. Alameda St. <br /> 9p,, CA 90222 (310) 037-7100 ;I <br /> I <br /> 9b.U.S.DOT Description.(Including Proper Shipping Name,Hazard Class,ID Number, 10•Containers 11,Total 12.Unit 13.Waste Codes <br /> t HM and Packing Group(If any)) E No. Type Quantity Wt.Nol. <br /> t UN1203, Gasoline Wixtura, 3, Pa II DM G 134 <br /> 2• <br /> it <br /> 3. l <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> liqA#t xsa pn sue. PROTECTivis BESI : 353065 <br /> Gasoline i Water CLtirTNIN6. QUI%STOP CCN-. 6592a7 <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 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 Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> ,I certify that the waste minimization statement Identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(Ill am a small quantity generator)Is true. <br /> GeneratorslOfferortPrintedlTypedName t. Signature ` Month Day Year <br /> 16.International Shipments El ❑ I' <br /> Import to U.S. Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: j <br /> 17.TransporterAcknowledgmenl of Receipt of Materials <br /> Transporter)Pdnte yped Name Signature Month Day Year <br /> Transporter 2 Printle yped Name Signature Month Day Year <br /> 18.Discrepancy ) �, <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type El Residue El Partial Rejection El Full ReJecdon <br /> f. <br /> I' <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number i. <br /> V Y <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facillty(or Generator) Month Day Year <br /> F j <br /> N <br /> 9.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 2• 3. 4. <br /> i <br /> 20..Designated Facility Owner or perator:Certification of receipt of hazardous materials covered by the manifest e>rf W;P'n ed In Item 18a. <br /> P n ed y ed Na a Signature ._ Mo th Day Yg9r� <br /> EPA Form 8700.22(Rev,12.17) F evIous editions are obsolete. TRAN POR ER CO Y <br /> 132/3152238 <br />