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Please print or type. .; Form Approved.OMB No.2050a39" UNIFORM HAZARDOUS 1• nerator ID 'Nurrtber of ergency s Phohe 4.Manifest Tracking Number WASTE MANIFEST C 1 L 0 0 0 0 4 3 1 41 1 .1600) 424-9300 F 'G 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) ' 4uik Stop !Markets, Inc. Quik St Markets, Inc. #132 165 Flanders Road ckton, C1� 9521 9 weat�arough, MA 01581 Generator's one: A 4-1122,101 6.Transporter 1 Company Name U.S.EPA ID Number BELSHIRE CARO 6 010 3 913 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Morld oil Recycling CAT 0 2 0 013 3 3 2 2000 N. 111amrda St. CA 90222 4310) S37-71N 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes i o X 1. U91203, Gasoline Kixture, 3, PG 1I DM a 134 Z 2. L 3. i 4. 14.Special Handling Instructions and Additional Information p�mm ram= 128 BESI :364609 i Gasoline i Motor CLtaTHI�G, p01UTOP CCU: 659231 15. GENERATOR'S/OFFEROR'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, p 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offeroes Printed/Typed Name Signature Month Day. Year I J 16.International Shipments F ❑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 Transported Printed/T d Name Signature y Month Day Year Z Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy { 18a.Discrepancy Indication Space ❑ Quantity El Type El Residue El Partial Rejection El Full Rejection I . i Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number _J V LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q i z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Mon h Day Ye V . ) EPA Form 8700-22(Rev.12 17) revious a li Ions are obsolete. TRANSPORTER C PY 132/3507794