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Please prim or[ype Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A L 0 0 0 0 4 5 9 3 1 1 (800) 924-9300 1 014261715 FLE <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Quik Stop Markets, Inc_ Quik Stop Markets, Inc. #138 <br /> 4557 Enterprise Street 1153 Lincoln Blvd_ <br /> Fremont, CA 94538 Tracy, CA 95375 <br /> Generator's Phone: ?510) 945-2282 <br /> 6.Transporter 1 Company Name U-S.EPA ID Number <br /> BELSHIRE <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> U.9- Ecology Nevada Operations N V T 3 3 0 0 1 0 0 0 0 <br /> Highway 95, 11 miles S_ of Beatty <br /> Beatty, NV 89003 <br /> Facility's Phone: (775) 553-2203 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No Type Quantity Wt.Nol. <br /> 1 Non-RCRA Hazardous Waste. Solid (ERG #171) Q 1 P 352 -,DO18 <br /> 0 (Rags, absorbent, & debris impacted with 0 <br /> petroleum hydrocarbons) a <br /> z 2 <br /> LU <br /> c7 <br /> 3. <br /> 4. <br /> 14.Spaclal Handling Instrueftris and Additional Information FOLD LABEL <br /> WEAR ALL APPROPRIATE $ESI : 313 5 7 9 LINE. AFFIX <br /> Generator is a RCRA. VSQG as defined in PERSONAL PROTECTIVE CCN- 659237 NIwStOE OF HA, <br /> 40 CFR 260.10. D018 code represents CLOTHING. µATEARBILL' <br /> waste that is RCRA identified but not TAB STICKS ON <br /> RCRA r-giilat-ed. PROFILE # 070214257-0 -1144 G+ <br /> 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, <br /> 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quanfi generator)is true. <br /> ratoesl0ffemes Printed7TypA Name --Signature Movith Day Year <br /> ?W EdEn%47 2D I 4 <br /> 16.International Shipments <br /> ❑Import to U.S. Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLI <br /> Transporter 1 Printed/Typed Name/ Signature Month Day Year <br /> CL <br /> /Ji oI,S L/�,�/C 17-1 z <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ QuantityEl yp 1 <br /> Type Residue Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Zi <br /> V <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Im 2- 3, 4. <br /> D <br /> 20.Designated,Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed yped NahmSlgn Month Da Year <br /> ti�bda bi—"— I <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />