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Please print or type. <br />Form Approved. OMB No. 2050-0039 <br />Ept;�Form 6700-22 (Rev. 12-17) Previous editions are obsolete. <br />UNIFORM HAZARDOUS1. <br />Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4, Manifest Tracking Number <br />WASTE MANIFEST <br />C A L 0 0 0 0 4 5 9 2 2 <br />1 <br />(800) 424-9300 <br />0137099493 FLE <br />5, Generator's Name and Mailing Address G nerajo s Si Address 0 d_iffere t than mailing ad ress) <br />�t_ti� top jMar�ets, VnC. #124 <br />Quik Stop Markets, Inc. <br />4567 Enterprise Street 505 N. Mein St. <br />Fremont, CA. 94638 Manteca, CA 95336 <br />{510) 445-2�8� <br />Generators Phone: <br />6. Transporter i Company Name U.S. EPA ID Number <br />BELSHIRE CARO 00183913 <br />U.S. EPA -ID Number <br />7 T spprter 2 Company Namew" <br />tt,, f <br />( AC. - �d W i <br />.a <br />8: Designated Facility Name and Sile Address- • • _ .. _.._ __.._ _ .......__ _. __..._ ..._-.... U.S: EPA ID Number----- --_ _.. <br />r <br />UeMenno Yerdoon it mfi <br />0A <br />2000 N. St. ` " <br />.Alameda <br />Campton, CA. 90222 <br />FadfrtyrsPhone: (310) 57-7100 <br />9a. <br />9b. U.S. DOT Description Qnduding Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />Waste Codes <br />HM <br />and Packing Group (f any)) <br />No. <br />Type <br />Quantity <br />WtNoi.F13. <br />1• UN1203, Gasoline Mixture, 2e PG II <br />K� <br />ff <br />`�i 3 <br />2. <br />W <br />3. <br />4. <br />14. Special Handling Instructions andAdditional Information WEAR ALL APPROPRIATE BES _ w 3 0 8 2 & 6 tr ¢• <br />ERG#: 128 PERSONAL PROTECTIVE <br />QUIT.STOP CCPI: 659237 <br />Gasoline E Water CLOTHING <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descfibed above by the proper shipping name, ani are classified, packaged, <br />marked and labeled/placarded, and are in all respects In proper condition for transport according to applicable intemationaland nation4govemmental 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 EPAAcknowledgment of Consent. , <br />1 certify that the waste minimization statement identified in 40 CFR 262.27(a) (d I am a large quantity generator) or (b) (III am a small quaptity generator) Is true. <br />Generators/Ogemr's Printed/Typed Name Signature Month Day Year <br />'' a d Jzl <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />E— <br />Transporter signature (for exports only): Date leaving U.S <br />W <br />17. TransporterAdmowledgment of Receipt of Materials <br />Transporter 1 Pdnted/Typed Nae D ` _ Signature ((� t Month Day Year <br />t `Z <br />a <br />ty� e i 1 \0."m- t` Nlocx- <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />¢z <br />M'..", <br />l <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b.NtemateFacility (or Generator) U.S. EPA ID Number <br />U <br />d< <br />Fadiity�s Phone: <br />w <br />18c. Signature ofAltemate Facility (or Generator) 4 <br />Month Day Year <br />Z <br />' <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />2. <br />20, Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted In Item 1 a <br />Printed/Typed NameSignature Mon Day Year <br />IesD 1 <br />��fIIo f Eli 119 <br />2092302 <br />DE VMA=TEI) FACILITY TO EPA's e-ttliANtFEST SYST M <br />