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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.Manlfest Tracking Number WASTE MANIFEST C A. 'L 0 0 0 0 4 5 E 9 9 1 (SDD) 47-3-93rie 013705393 ELE 5.Generator's Name and Mailing Address Generalces Site Address(If different than mailing address) Quik Stop Merkets,' Inc- Qttik Stop Markets, 111c- ##07.6 4567 Enterprise Street 1030 S- Olive Ave. Fretuont, CA 94S38 Stock-Con, CA 95215 Generators Phone: (510) 445-2?82 6.Transporter 1 Company Name U.S.EPA ID Number BELSHIRG CAR0 0 0 1 0 3 9 13 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number DeMenno kerdoon CAT 0 8 0 0 13 3 5 2 2000 N_ Alaraeda.St- Cornpton, CA 90.222 Faclilly'sPhone: (310) 5�7-7Z00 9a, 9b•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 Cif any)) No. Type Quantity Wtfvol. a 1' Ulgl203, Gamoline Mixtuce, S, RG I1 G 134 DPAI CAC0- i 2, w C7 3. A a ' 4. 14.Special Handling InsUmdons and Addiflonal Information �� WEAR ALL APPROPRT�.TE BEST . u 1 2 2 3 g E. A ERG,#: 126 PER3011AL PROTECTIVE � so 0 G�salanc G 11x1 eE CLOTHI11G. 413IA9`IOP CCN: 658237 A 2 x 58 T it zroa 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby dedare 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 Inlemational and national governmental regulations.If export shipment and I am the Primary Exporter,I certlly that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 1 certify that the waste minimization statement Identified In 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(if I em a small quantity generator)Is true. a enalorsl0(ferorsPrinied/yped Name ( Signature Day Year 116.International Shipments r— ❑Import to U.S. ❑Export from U.S. Port of entrylerdl: ? Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Admowiedgmenl of Receipt of Materials Transporter 1 Prin ed Name p� "'Signature Month Day Year a Transporter 2 Printedf yped Name Signature Month Day Year I— 18.Discrepancy 18a.Discrepancy Indication Specs ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number U LQ Faclllys Phone: UJ 18c.Signature of Alternate Facility(or Generator) Month Day Year N19,Hazardous Waste Report Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 T__ 20,Designalod Facility Owner or Oporater:Cer98callon of receipt of hazardous materials covered by the_manifesl except as noted In Item 18a Pdnfe/Typed ams Signature Month Day Year �1V1 Iia l- o Y-61 v-5 -1 111 0 -41 EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGKATF:__D:F=ACILITY TO EPA's e-MANIFEST SYS7 M 076 2166968