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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3. rgency Response one n ra g umber <br /> WASTE MANIFEST CALOW2807M 1 1-800-424-9300 015 4 57105 JJ K <br /> S.Generator's Name and Mailing dress Safeway Incj Vans Generators Site Address(if di nern than mailing address) <br /> 5918 Stoneridge Mail Road Attn: Sharon Plouffe Safeway Fuel#2707 _ <br /> Pleasanton,CA 94588 6525 North Pacific Avenue <br /> Generators Phone: 626$21-6192 Stockton, CA 95207 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Environmental Logistics, Inc. JCAIR000172460 <br /> T Transporter2 Company Name S.EPA ID Number <br /> 8.Designated Fealty Name and Site Address U.S.EPA ID Number <br /> Haznlat, Inc. <br /> 6300 Stadium Drive, Kansas City, MO 64129 <br /> Facilltysphona;816-924-5884 WD981123391 <br /> 9a. 9b.U.S.DOT Description(including Prater Shipping Name.Hand cast,ID Number, 10.Containers 11.Toni 12.UnR 13.Waste Codes <br /> HM and PacMrg Group(Ir any)) No. type Dumbly WidVol. <br /> c <br /> LIN 1993, Waste flammable liquid, nos(gasoline) <br /> X 3; PG II ` - 7 1 `'DM 20 " P <br /> z 2. <br /> W <br /> A <br /> 3. <br /> 4. <br /> i <br /> 14.Special Handling Instructions and Additionalmmtion tzmergealut,RE0141CRIMS,CHEM I REU I- - <br /> 9b1)Profile# AES-62742 ERG#128 1 x 55 <br /> Rejected from manifest#014891372JJK <br /> 15. GENERATOR'SIOFFEROR'S CERnFICATIGN; 1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dessified,packagbd, <br /> marked am Iabeledlplapmed,and are in all respects in proper condition for transport according as applicable intamationaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter.I certify,Nat the contents of this consignment conform to IN terms tithe aberned EPAAcknowledgment or Consent. <br /> I mrtify that the waste minimization statement identified In 40 CFR 262.27(a)(If t am a large quantity gerrerator)or(b)(MI am a small quantity generator)is true. <br /> GeneratorsfO6ames Pdntsdfryped Name Signature - ' Monty y yes <br /> Steven Masters, offeror I 3 7 U/ <br /> F 18.International Shipments ❑larwb U.S. ❑Exwrt from U.S. Pat afanayderit <br /> M Transporter signaluns(for exports only): Date leaNrg U.S.: <br /> 17.TransporterAdmawledgmenl of Receipt of Materials <br /> Tram 1 Prot N7 Signanot M Day Year <br /> 1317 11toN <br /> Q Trensparler 2 �nted/Tvped Name Signature Monty Day Year <br /> C <br /> 18.Discrepancy <br /> 18X.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rated., ❑Full Rejection <br /> Man"Reference Number: <br /> 16b.Alternate Facility(or Generator) U.S.EPAID Number <br /> U <br /> rai Faciklys Phone: <br /> 1 So Signatureo emate Facility or Generator Month Day <br /> Q <br /> 2 <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazamous waste Vestment disposal,and recycling systems) <br /> 1. /) 2. 3. 4. <br /> 20,Designated Fedllty,Ovm7er or Operator.Certification of rewlpt of hazardous materials covered by the manifest weeptsuoted In Item fee <br /> Pri <br /> m 'mJ//1 C I �L ,, naNre <br /> EPA Form 8700.22(Rev.345) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />