COMPLIANCE INFO_2025 - Laserfiche WebLink

Home Browse Search

i j Please not or r P fx• Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking umber a WASTE MANIFEST C Jk L 0 0 0 0 e IS 9 1 (800) 424-9300 017547522 FLE 5.Generator's Name and Mailing Address Generstor's Site Address{if different than mailing address) Qu1k Stop Markets, Inc. Quik ios Sttat Markets, Inc. 0144 1165 Flanders Road Stockton, CA 95210 Weetborough, KA 01581 Generator's Phone; 8.Transporter 1 Company Name U.S.EPA ID Number BELSHIRE C JL R 0 0 01 .3 913 7.Transporter 2 Company Name U,S,EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number World oil Recycling CAT 0 ' 0 01 3 3 S 2 2000 N. Aiameda St. C I1Iyhtone:an, CA 90222 4310) 537-7100 II SP 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 Wtivoi, 13.Waste Codes c UN1203, Gasoline Mixture, 3, PG II G 134 z 2. W 0 3. 4. - I 14,Special Handlinglnstructions and Additional Information 1/1F11a ALL APP>ROPRIATii ter: iZ8 PERSONAL PROT19CTIVB BES I : 3 5 4 6 3 0 1 Gasoline i Water CLOTHING. QUIRSTOP CCNr 659237 V 1 i 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 ciassilled,packaged, 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,1•certKy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. i I certify that the waste minimization statement identified in 40 CFR 282.27(a)(If I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generators/Offemes Printed/Typed Name Signature Month Day Year J 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: IX W 17.Transporter Acknowledgment of Receipt of Materials Transporter Printed/Typed Signature -) Month Day Year Q Lam, c t3 Z Transporter 2 Printed/Typed Name Signature Month Day Year H 18.Discrepancy I 18a.Discrepancy Indication Space ❑ Quanta F ty ❑Type ❑Residue ❑Partial Rejection Full Rejection I Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number V u. Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year I H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) W 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as ndW In Item 18a tTyped Narne, *. f _.. �: 9nature . ._ Month ay ear: EPA Form 8 00.22(Rev.12.17) Previous editions are obsolete. TRANSPORTER COPY 144/3222063