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loiases,print or type.(Form designed for use on elite(12-pitch)typewdler.) Form Approved.OMS No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Genamtor ID Number 2.Page 1 of 3.Emergency Response Plane 4.ManNestTracking Number <br /> WASTE MANIFEST CAL000280766 1 1-800-124-9300 015457105 JJ K <br /> 5.Generators Name and Mailing Address zsaTeway inl!7voris Generators Sm Address(if different than mailing address) <br /> 5918 Stoneridge Mall Road Attn: Sharon Plouffe Safeway Fuel#2707 <br /> Pleasanton, CA 94588 6525 North Pacific Avenue <br /> Genemlo(sPhone: 626-821-6192 Stockton,CA 95207 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Environmental Logistics, Inc. ICAR000172460 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and She Address U.S.EPA ID Number <br /> Hazmat, Inc. <br /> 6300 Stadium Drive, Kansas City, MO 64129 <br /> Facfiiys Phone:616-92456$4 IMOD981123391 <br /> %, 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class,ID Number, 10.Containers ii.Total 12,Unit <br /> HM and Packing Group ftiany)) No. Ty11e Quantity Wt Not. 13.Waste Codes <br /> c 1 LIN1993,Waste flammable liquid, nos(gasoline) D001 D018 343 <br /> x 3, PG II 1 DM 20 P <br /> W 2. <br /> 3. <br /> r I <br /> 4 <br /> 14.Special Handing Instructions and Additional Information Emergency <br /> 9b1)Profile# AES-62742 ERG#128 1 x 55 <br /> Rejected from man fest#014891372JJK <br /> 1 GENERATOR'SIOFFEROR'S CERTIFICATION:1 hereby declare gut the contents of this consignment are fully and accuratey described above by the pmparshipykrg name,and are classified,packaged, <br /> marked and IabeNNplacanded,and are in all respects in p DW condition for transport according to applicable international and national governmental regulations.If export sNpmmnt and 1 am the primary <br /> Exporter,I so,"that the contents of this comignmem burden to the tams of the attached FPAAd=Wedgment of Consent. <br /> I codify that the waste m idarkation statement identified in 40 CFR 262.27(x)(d I am a large quantity generator)or(b)(81 am a small quantity generator)is bbe. ' <br /> GeneaWs1011emrs Primedrryped Nam Sqmabm <br /> �r�r kbnN Div Y <br /> Steven Masters,offeror <br /> -J 16.Intemetional Sripments <br /> r— ❑Import it U.S. ❑Export from U.S. Port oferNylexit <br /> z Transpoder signature(for exports only): Data Iaxoirp U.S.: <br /> W 17.TransporhrAdmeWetlprhntofReceipt of Materials <br /> Transom 1 PdMgN�p�Naroe Signature Month DeY Yaer <br /> a / , 1/ <br /> a <br /> Transporter 2 PmmVyPedSignaNre Math Day Year <br /> 1 18.Discrepancy <br /> I 18a.Disempancy Indication Space ❑ puentry ❑Type ❑Resklue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b..Altemate Facility(or Generator) U.S.EPA ID Number <br /> • U <br /> raa- Faciltys Phone: <br /> W18c.Sliptaturs of Alternate Facility(ofGenerator) Mon Day Year <br /> a <br /> Z <br /> H19.Hazardous Waste Report Management Method Coda(I.e.,codes for hazardous waste treatment disposal.and recycling streamers) <br /> G 1. 2. 3. 4. <br /> 20,Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the menilest except as noted In Item i8a <br /> me erne Signature Month my ear <br /> EPA Form 8700-22(Rev.3.05) Previous editbns are obsolete. GENERATOR'S INITIAL COPY <br />