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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number C WASTE MANIFEST C A L 0 0 0 0 4 5 9 3 1 1 (800) 424-9300 014679596 1 C LE 5.Generators Name and Mailing Address Generatoes Site Address(if different than mailing address) QQ Quik Stop Markets, Inc. ?153 StopMarkets , Inc. #138 165 Flanders Road Tracy,Lincoln 95376 Westborough, MA 01581 Generators Phone: (510) 445-2282 6.Transporter 1 Company Namc U.S.EPA ID Number BELSHIRE CAR 0 0 018 3 913 7.Transporter 2 Company Name US.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number U S. Ecol gy Ne oda Oper tions a V T 3 3 0 010 0 0 0 Highway 9g, 'j1 tt�� les S. of Beatty Beatty, NV 8900 (775) 553-2203 Facility's Phane ga 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 WLN61. 1 Non-RCRA Hazardous Naste, .Solid (ERG #171) P 352 *D018I o (Rags, absorbent, & debris impacted with , r --- petroleum -petroleum. hydrocarbons) Z 2 W C9 3 4 14-Special Handling Instructions and Additional Information NEAR ALL APPROPRIATE . FOLD LABEL AT DOTT1 Generator is a RCRA VSQG as defined in PERSONAL PROTECTIVE BEST . 322601 LINE. AFFIX TO RIGHT 40 CFR 260.10. D018 code represents CLOTHING. QUIKSTOP CCN: 659237 SIDE OF HAZARDOUS waste that is RCRA identified but not MAT ERIALBILLS SOTHAT RCRA regulated. PROFILE # 070214257-0 I� $S ( TAB SflCKS OUT. 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,pacxage 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 C90sent, I certify that the waste minimization statement identified in 40 CFR 262 27(a)(if I am a large quantity generator)or(b/j1 am a small quantity generator)is true. Generator's eror's PdntedlTyped Name Signature Month Day Year ?I!Zit I L I IT dk— 7-,C2 '16.Intemillional Shipments ❑Import to U.S. ❑Export from U.S. Port of entryfexit: ? Transporter signature(for exports only): Date leaving U.S.. W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature oo Month Day Year CL z Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity Type E Residue El Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 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 PriRte !TypedN e O Signature Month y Y_ear �j "(]/0 EPA Form 8700-22(Rev.12-17) Previ s editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM