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Please print or type. Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1 1,Generator ID Number 2.Page i of 3,Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C A L Q 0 0 d 4 5 9 3 000) 424-9300 014261722, FLE 5.Generator's Name and Mailing Address Generator's a Address if different than mailing address) C�uuik SiNik Stop Markets, Inc_ QopMarkets, Inc. #):138 4507 Enterprise Street 1153 Lincoln Blvd. Fremont; CA 54538 Tracy, CA 95376 Generator's Phone: (510) X45-2282 6.Transporter 1 Company Name U.S.EPA ID Number BELSHSRE• C A RQ 0 D 1 $ 3 9 1 3 7.Transporter 2 Company Name U.S.EPA ID Number 8,Designated Facility Name and Site Address U.S.EPA ID Number DeMenno KerdoonT @ €b�! ;� 2000 N_ Alameda St_ 352 Compton, CA 90222 Facilitys Phone: (310) 527-7100 ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, f0.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No, Type Quantity Wt.Nol. 1 UN1203, G2zcline Mixture, 3, PG TI oa X60, 134 W 3. 4. 14.Special Handling Instructions and Additional Information WEAR ALL APPROPRIATE B E S I e 313 5 7 9 6OLO LAUI ERG#: 128 PERSONAL PROTECTIVE UNE.AFF Gasoline a Water CLOTHING, CCH: 68923`! SIpE OF� ' .Mf1TENIAL• �oev 15. GENERA70R'SlOFFEROR'SCERTIFICATION; 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'Pdmary 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)(III am a small quantity generator)is true. Gerierator's/Offeror's Printed/Typ Name S.��ig-nature Mo lh Day Year k 1:r h 16.International Shipments V ❑Import to U.S. ❑Export from U.S. Port of entrylexil: z Transporter signature(for exports only): Date leaving U.S.: W 17.Transpodg'%Ack 9wiedpmept4q(Receipt of Materials )i2 Transporteejr I Pdritedffyped N�arq):. Signature Month Day Year lw Z Transporter?zPr edlTyped Name.'; Signature Month Day Year 18.Discrepancy 18a.DiscreArcy,intlication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U LL Facilitys Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 19.H zardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Prinledfryped Name Signature Month Day Year EPA Form 8700-22(Rev,12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e,MANIFEST SYSTEM