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2018-02-01 10:56 Safeway 2707 2094728604 >> 2094683433 P 5/8 <br /> Please pfint or type,(Form designed or use Or ghee(12•pildl)typewriter.) Form Approved,OMB No,2D50-0(k99 <br /> UNIFORM HAZARDOUS 1.Genemer 10 umber 2Pago lM 3 Emogency,ROWSO Phone 4.Manifest <br /> s Ta,racking Number <br /> WASTEMOUFST e <br /> JJK <br /> 6.Gogr Ws Nameand MalmgAddro6a GemmlNs SdeAddrasc(86FeraM Ihan rrgifingaddress) <br /> ''n^,r9< :i9ni's:It1- !'$Foye iFr'•;r: ii,lf�l+4)J L'.-..:. <br /> y.i :i'nicp?f i:_;frv•'.It <br /> Genamteys Roans: <br /> B.Tmnapormr 7 etmpany Narrre U.S.EPA ID Number <br /> 7.Tranaponer2 Company Name U,S,EPA IO Number <br /> 8,Designated F30011 Nand and Site Address; US.EPA ID Number <br /> fit)t4t:I'3axh�:MMr,ststvktrei, i+:+, <br /> ijs[j}A,:,RQOM9 AtakFit'G' . <br /> f+{9oT:.darg!OS'r Z3A S)PMC- <br /> Far78y'sPhone: 4.y o+t:". +• !} ) {,'.. e). :.i :1 , <br /> ga, <br /> Bb.U.S.DOT 0e9c6pllar(indub(ng PWShppa'g Name,Hazard Class,ID Number. In.Conlein8% 11.Tabl 12.Unn <br /> HM and PACWWO+D?PUIaDY1) rvo, Type Qum* WL/Val.oc <br /> 13.WeeM(kdes <br /> 1{IA4."87ci.'sclkdscotYFtllMiryllaatltribreTkrlitcv'r'!,t::,a rfe;x:rc;a�.:�r:^, . ry. <br /> o <br /> DO <br /> ' I <br /> z z, <br /> DO <br /> 3. <br /> I <br /> I <br /> 4, I1H <br /> 14.8perlel Hmdanglnstrucba aT4Addkt iliknmabn lit!x)�iVS 'i;:;x?Ia+1D;:fl..4'Iy):;c".:,Pier,::' S:IIA fStttuh'ia:4l4ay' I1Str 1•lf+L:rnry'OV; <br /> 15. GENERATOR'SIOFFEROR'SCERTFICATION:I hereby declare nal the Moves of this conuenmed are lu#y and accurately described above by the Weewellbdr,g name,and are classified.packaged, <br /> norked and L16eleft0carded,and are In all reepecle in proper co diton for transport according to applicaNa imoma ionaland naeomW govemmmbl regdalbre.If expodahpnent and I am the Primary <br /> Exporter,I mrtifynat the contents of tNs consignment conform to the tons Of and attached EPAA0AD%4edgrnenl of Cadent. <br /> I certityMel Ihaxasfe mirfirm atlon statement idanbTied in 40 CPR 262R7(a)(III am a huge 4uenblyBenerela)or(b)(ill am a smell quantilyganarela)is WD. <br /> GenamWye108arWe PinhFIlyped Name s4wDre / Month Day year <br /> J 16.hnemadonal Shlpmenls; <br /> I— ❑hnpalb U.S ❑Eap4rl from US, Podol enlryyexib l ,,, <br /> Ranspaterslpnalum(la exporre orly), Dole leaving U.S.: <br /> w 17.TwepodwAdnvNWgmwofReceiplof Malenals <br /> p, T2rqa1at l PHmodllyped Name Signature Month Day Year <br /> Y Trmdpwrer2Pdnledffyped Nome SgnaNre MOMS Day Year <br /> Q2 <br /> r <br /> T18.Dbooprq <br /> 10x.Discrepancy lndbatlon$pace ❑ ❑TYPE ❑Residue ❑PaNalRwhde ❑Ful%ation <br /> Mandot Refven m Number: <br /> 18b.Aramem Fadily(orGanaraxt) U.S.EPA ID Numaer <br /> V <br /> a FaclityY Phook <br /> W lk.8Nralure olatematC Fac tv(m Genonuar) Mmnih uay Yeer <br /> 6 <br /> Z <br /> m19.Hasardoes Waste Report Management Method Codes g.c.,Godes for ha udoM Waste twimamt disposal,and reaycng systems) <br /> IU 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator..(%afiradon of receipt of hexardous matsrWscovemd by the rcatNest except as nCed'n llem lee <br /> Pdaledrryped Name Sashes Mcnlh Day Veer <br /> EPAForm8700-22(Rev.3-05) Previous editions amobsalate. GENERATOR'S INITIAL COPY <br />