COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C A L 0 0 0 0 4 3 3 3 $ 1 (800) 424--9300 1015004646 FLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Quik Stop Markets, Inc. Quik Stop Markets, Inc. #120 165 Flanders Road 9321 Thornton Rd. Westborough, MA 01581 Stockton, CA 95209 Generator's Phone: 510) 445-2282 6.Transporter 1 Company Name U.S.EPA ID Number BELSHIRE C.AA 0 0 0 18 3 913 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number World Oil Recycling CAT 0 8 0 0 13 3 5 2 2000 N. Alatncda St. Compton, CA 90222 (310) 537-7100 Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity WtNol. 13.Waste Codes 1 UN1203, Ga3oline Mixture, 3, PG II G 134 o LU 2. 3 4. 14.Special Handling Instructions and Additional Information FOLD!ABEL AT�DDTTE" CRGf: 128 WEAR ALL APPROPRIATE BEST : 3 2 6 2 3 2 L1t7E AFFIX1r,TO_ ldG Gasoline & water PERSONhL PROTECTIVE QUIKSTOP CCU: &59237 S10 0 HAZARDOU CLOTHING. MATERIAL 81LLS'S01 TABSTICBSO�UT.n4,'' 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,aryl are classifie,pac age 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)("dl am a small quantity generator)is We. Generator' Offeror's Printed ypaj ed Name Signature Month Day Year t F js2ja �� I Iq J 16.Internatlonal Shipments ►— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials H TransporteFrNntedn,yped Name Signature Month Day Year Transporter 2 Printed/Typed Name Signature Month Day Year F- 18.Discrepancy. 18a.Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J v rai Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) a Month Day Year a 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Namer— ignature Month Day Year � ` Yatesz. � � EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST`SYSTEM