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Please print or tvoe Form Approved. OMt3 No. 2050-0039 EPA Form 4700-22 (Rev. 12-17) Previous editions are obsolete. 124 2117391 DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM UNIFORM US 1 Generator ID Number 2. Page t of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MAN EST C A L 0 0 0 0 4 5 9 2 2 1 (eoo) 0924-9300 012773283FLE 5. Generators Name and Mailing Address r�ene tis S' e Address 'f iffere t than mailingdress built Stop �ne'} Qui} Stora Markets, Inc- ar�ets, #124 4567 Enterprise Strut 505 N. Main St. Fremont, CA 94538 Manteca, CA 95336 (510} 445-22$2 Generator's Phone: 6, Transporter 1 Company Name U.S. EPA ID Number sELSHTRE C.AR0 0 0 1 0 3 9 13 7. T spsrter 2 Company Name U.S. EPA ID Number �'� i �/ 1x� lJ t 8. Designated Facili Name and Site Address U.S. EPA ID Number DeMenno Kerdoon C, T 0 0 0 0 13 3 2 Compton, A'T 992 - FacilitysPhone: (310) 537-7100 ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11. Total 12. Unit 13, Waste Codes HM and Packing Group (if any)) No. Type Quantity Wt.Nol. 1• UN1203, Gazoli.ne Mixture, 3, PG II G 134 Z 2. w 0 3. 4. 14. Special Handling Instructions and Additional Information WEAR. ALL APPROPRIATE B E S I w 3 O 9 4 C9 3 ERG#;:: 128 01 PERSONAL PROTECTIVE QUIK3TOT CC1q: 653237 � Gasoline & Water CLOTHING. 15, GENERATOR'SlOFFEROR'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, 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 EPAAcknowiedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity genera r or (b) 'fl aT a small quantity ge tor) is true. G lor'slOfferors Printed/Typed Name Sgna re Month Day Year VW10 x 2 a 16. International Shipments El Import to U.S. ❑ Export from U.S. Port of entrylexit: Transporter signature (for exports only): Date leaving U.S.: 0� 17. TransporterAcknowledgment of Receipt of Materials 2 Transporter 1 Prinledfrype a Signature ` -` Month Year 17 CL t. \ J Trans rter rined/T ped tName Signature Month Day Year > ZZ 18, Discrepancy 18a. Discrepancy Indication Space El Quantity ❑ Type ❑ Residue ❑ Partial Rejection Full Rejection Manifest Reference Number: 18b, Alternate Facility (or Generator) U.S. EPA ID Number J V LL. Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) W 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 PrintedlTyped Name It,' boa M t es Signature Mont Day Year z I i o EPA Form 4700-22 (Rev. 12-17) Previous editions are obsolete. 124 2117391 DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM