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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C A L 0 0 0 Q 4 5 9 3 1 1 (800) 424—93 00 012173092 FLE 5.Generator's Name and Mailing Address Generators Site Address(if_different than mailing address) Quik Stop Markets, Inc_ Quik Stop Markets, Inc_ #138 4567 Enterprise Street 1143 Lincoln Blvd_ Fremont, CA 94538 Tracy, CA 9S376 Generator's Phone: (510) 445-2202 6.Transporter 1 Company Name U.S.EPA ID Number BELSHIRE C A R.0 0 018 3 9 13 7.Tra sporter 2 Company Name U.S.EPA ID Number �� t '3� 1 U Ru 8.Designated Facility Name and Site Address U.S.EPA ID Number DeMenno Kerdoon CAT 0 8 0 0 13 351 2 2000 N_ Alameda S _ Compton, CA 5022 Facility's Phone: 4310) 537—'7100 9a. 91b.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, Gasoline Mixture, 3, PG II G 134 z 2, LU c7 3. 4. 14.Special Handling Instructions and Additional Information WEAR .ALL APPROPRIATE B E S I ` 2 9 7 3 J 4 ERG#: 125 PERSONAL PROTECTIVE Gasoline 6 Water CLOTHING_ QUIR3TOP CCN: 659237 xs 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, 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 EPA Acknowledgment 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)(if A9 a small quantity generator)is true. eratoes/Offeror's Pdrited/Typed }Name I ure q ay Year J 16,International Shipments F— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: rW 17.Transporter Acknowledgment of Receipt of Materials LU Transporter 1 Printed/Typed Name Signature Mont ay Year d z Transporter r' ed(fyVdNe Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Typej ❑Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ U Q LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 19.tzardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 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/Type Name Signature Mont Day Year d � o EPA Form 700-22(Rev.3-05) Previous editions are obsolete.