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2018-02-01 10:52 Safeway 2707 2094728604 >> 2094683433 P 3/8 <br /> Please printoktypo (Forty designed for use on elite(T2•pitch),typeWrilei.) FurnApproved.OMB No.2050 M9 <br /> 116111 6RMWAROOU9 1.GaimmalorlO Number 2.Paplof 3. mergallsy Reapome Phone 4.NenNesa Tmckdng Number <br /> WASTE MANIFEST 01-14 45713 JJK <br /> 7116.Generator$bare and Mmling AAdrees Gemaralces$eRAddrns(tl dJlerent lhon mi[N oddrese) <br /> Generl Phone: <br /> 6.TraMp4Mf 1 Company Name U.S.EPAID Numbs, <br /> T.Transporter(kmpany Name 4S,FPA ID Nutaar <br /> 9.Desgnated FOORYName and ShcAddmss U.S.EPAID Number <br /> Faril plane: . <br /> eA 9b.U.S.DDT Description(in4hdlog Proper Shlppng Name,Hamrd Claes,ID Numbef 10 Cpnta,ners 17.Total 12,Ung <br /> HM and Pa*)g Group(if any)) No. Type Cuenbly INIArq• 13.Waste Coda <br /> p <br /> 2. <br /> f7 <br /> 4. <br /> . 14. tial HandNng lnatrue8ons am Addaimul miamsean . . . <br /> r <br /> 15, GENERATOW81OFFEROR'S CERTIFICATION: I hveby Were that ate cordetds Of this cenalgnmenl WO Nly'and xGlNalory described above by ate proper shlppng name,and are clawed packaged, <br /> marked and lebzledlplacardad,and are in all tespeds In proper wtMidon for transport according Is applicable IMnratMetand normal 9 mnmeMad ro uptlons.H export shipment g p erM tem the pHmary <br /> Ekporlar,lcettiy Tatthe contents of this wnslpnnlent conform tethe tame of the attached EPAAdmovrkdgtremof canctrm" <br /> •4osdly that the mate minimgafon statement idended In 40 CFR 262,27(a)(it I am a large quanatygenemtor)or(b)(HI am a smalpuadHy generator)Is true. <br /> Gene?to(sl)4#W8 PrintedlT dName t $Ignotim " . Month Day Yeer <br /> F <br /> F 19,International SNp,'neats <br /> ❑Im4»RtO U.S. ❑Expod lrpn U.9. PoAdentrylexa: _ <br /> ? Tranapoder signature(for expods ony): Data leaving U.S.: <br /> 17.TransporterAdmowteagmentof RecaiptofMaterials <br /> CTmeppmter l PrtYA&Typad Nems Slenatwe Month Day Year <br /> 0s <br /> a Transporter 2 PmaudrFyped Nems S'gnslum j, hkn:h Day Year <br /> 1 <br /> 16.Discrepancy <br /> 18a.OisurapanoylydaatWn Space ❑ quantity 1:1 Type ❑Residue ❑Partial Raiattion ❑Fua Rejection <br /> Manliest Rekrolac Number. j <br /> 18b.Alternate FocOry(Or Gemaretor) U.S.EPA ID Number <br /> a t <br /> LL FaDlity's Plane: <br /> Maj 18c.Signahae ofAllemete Fadhy(orGmaraerq <br /> r Monet Day Year <br /> Q <br /> 2 <br /> 'D t IS.Hazardous Waste Report MarKVmeM Meaed Codes(I.e..codes fof harerdoW waste bealmot,disposer,aro ie Wirg systems) <br /> 1• 2 a. d. <br /> 20.beslgnstee FadNy Omar or Operator:Cerdficauon of reregt of hmadoue mammals covered W Me nonjust enrapt a Med M Hem 18a <br /> FnmWW IYPW Name Sigwum Month Day Year <br /> ERA Forint 8700,22(Rev.3.05) Previous 04truts are obsolete, GENERATOR'S INITIAL COPY <br />