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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.Emergency Response Phone 4.M{anini st racking Numbe'r� <br /> WASTE MANIFEST CALOOCM5940 1 8M 424-93M �4660t23 FLE <br /> T. enerator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Quik Stop Markets, Inc. QtA St rketa, Inc. 52 <br /> 4567 Enterprise Street 1721S okee Ln. <br /> a 'S'P?tibn ' f f338 (5101445-2282 Lod,Cdr 95240 <br /> � <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> BELSHIREC-AREttlO183913 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> DeMenno Kerdoon <br /> 2000 N. Alameda St. CATOBOO13352 <br /> I pp. CA 90222 (. 5. 7-7 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit <br /> HM and Packing Group(ii any)) No. Type Quantity M.Nol. 13.Waste Codes <br /> 1. <br /> o UN1203. GaasNine Mixture, 3, PG it � ! C 134 <br /> L z. THIS WASTE STREAM HAS BEEN (QUALIFIED <br /> FOR RECYCLING/TREATMENT AT THE <br /> 3. <br /> CALIFORNIA.THIS FACILITY HAS T1IE NECESSARY <br /> PERMITS TO RECEIVE YOU R 'v`:r^STE STREAM AS <br /> 14.Special Handling Instructions and Additional Information <br /> ,_AR ALL aPPROP�tixT'E E3��1:2OdtlC�S <br /> ER 12'3 QUIK STOP CCN: <br /> Gascfflne &Water PROTECTIVE CLOTHING. 237 <br /> / <br /> 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 classified,packaged, <br /> 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> enerato e s PrinteNTyped Name bignature, Month L)ay Toar <br /> 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature for exports only): Da,%leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials 1' <br /> Tran rt rter not ype ame Signature y r <br /> CL <br /> 0) S ,VY _ � - <br /> za Transporter 2 Printed/Typed Name Sighase- Month Day Year <br /> cc <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type El Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Faciiity(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> ►L <br /> Facilitys Phone: <br /> W 18c.Signature of Ntemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> u, 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2, 3. 4. <br /> 20.Designated Facility Gamer or Operator:Certification of receipt of hazardous materials covered by the manif py`as pted in Item 18a <br /> Prints ype ' i <br /> Ad <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete.. i' "'~ DESIGNATED FAC lL TO GENERATOR <br />