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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C a Q' Q 0 0 . .� ;"1 S 1 1600) !2!-}300 016572766 F LE 5.Generators Name and Matting Address Generalor's Site Address(It different than mailing address Quik Stop Karketa, Inc. i, 2 C'af MLLn�srket�, Ina. �i!! 165 !'lenders Road � , c1►� Westborough, NA 01501 et.toaktom9510 Generators Phone: (310) 443-22921- 6. 45-2292 -6.Transporter 1 Company Name U.S.EPA ID Number ULSHIRE C iR 0 0 010 3 913 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number World- Oil Recycling CAT 0 0 0 013 3 33 2000 N. Alaeteda St. CoApton, CA 90222 (310) 537-7100 Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit and Packing Group if an 13.Waste Codes HM p( y)) No. Type Quantity WLNoI. R 1. UN1203, Gasoline Mixtulto, 3, Pia II O 134 o w w 3. li is 4. 14.Special Handling Instructions and Additional Information WIM ALL AtI1111140"IAT2 BES I : 3 3 4 15 7 �114/i 1:5 PBROONAL rll0'TSClIVil 6ss01ino i Mater !?LO?HIli1Q. CMIKATOP CCN: 659237 X 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 propercondition for transport according to applicable intemallonaland national govemmenlal 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 EPAAcknowledgmenl 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 I am a small quantity generator)is true. Jyp g �.�f;/ Month Dy Year Generators/Offerofs Printed/Typed ed Name nalu a�--� Si � I / , 16.Int malional Shipments ❑Import to U.S. ❑Export from U.S. ^Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporier9 rinled/Typed Name Signature Month Day Year a Z Transporler.2 Printedrfyped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ ❑ ❑ ❑Full Rejection ❑ Quantity Type , Residue Partial Rejection / Manifest Reference Number: 18b.Allemate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature of Allemate Facility(or Generator) Month Day Year Q Z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLJ1. 2. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a Printed/Typed Name - Signature Month Day Year IM 123 12 I EPA Form 8700-22(Rev.12-17) Previous editions are obsolete: TRANSPORTER COPY 144 2645932