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Please print or type. (Form designed for use on elite (12-pircnl typevvriter.)*r 11 '-"-`form Approved. OMB No. 2050-0039 EPA FdW6M0-22 (Rev. 3-05) Previous editions aFebbsolete. Y Z DESIGNATED FACILITVTO GENERATOR UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of r 3. Emergency Response Phone 4. Manifest Track'Number 009160147 J J K WASTE MANIFEST C A D 9 8 2,5 0 8 2 5 1 1 1909.389.5607 5. Generators Name and Mailing Address Generator's Site Address (if different thagmailing address) Ureled Grocers Unffied Grocers f Atte: Pat GlAker rIety.,5200 Shelia 8irae't 1990 Piccoll Rd. Canmerce 'CA 90040 r Stockton CA 95215' Generator's Phone: 7 3 6 4 57 6. Transporter 1 Company Name U.�"EPA ID Number Hao klat Trans, Inc.--';' - �i A Y 0 8 0 0 1 2 8 '0 0 7. Transporter 2 Company.Name i" U.S. EPA ID Number { 8. Designated Facility Name and Site Address U.S. EPA ID Number DeMerxx erdoan 2000 K Alameda Street Compton CA 90222 Facility's Phone: -71 �' -` C A T 0 8 0 0 1 3 3 5 2 ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number,' �' 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing if an 9 Grou p ( y)) � Quantity Wt.Nol. O 1Non-RCRA Hazardous Waste Liquid ... .�"' 221 -- TFC .�'-� �� G L W c' 2. AS BEEPI QUALIFIED FDR q�t^'rt.l�,' ```,,..?{{ ( CWT I CL /- EATMENTS AT THE � 3, iL li�i1�Ti ♦!r f. i'..'. r.r 4�J1�ilIV !�ltl DTON, r, i�.tl l.i''r f r�'iS EE PERMITS TO R;: -,-p yoESSnRY /F 'rr J L 2 20T4 �+1� 7 4. r( ttjA NUI�1BER JS CAT0800133�2 � L_ EN IRO 14. Special Handling Instructions and Additional Information 9b.1) WASTE OIL Y_ �G Gloves & Goggles Jpko-ikiti 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,`ackaged `Hmary 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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. t GeneratoeslOfjero s,P�'^ted/Typed Name 1 eP Signature * Month Day ; Year _j 1 16. International Shipments _ ❑ Import to U.S. ❑ Export from U.S. Port of entryexit: Z Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name/ SignatureMonth Day Year a Qransporter 2 Printed/Typed Name Signature Month Day Year F 18. Discrepancy 18a, Discrepancy Indication Space ❑ Quanti ElT e ❑ Residue ty Type EJ Partial Rejection El Full Rejection -a Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J L) Facility's Phone: U 18c. Signature of Alternate 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) G 1. r 2. 3. 4. 20. Designated FacilityOwner or Operator: Certification of rete' t of hazardous materials covered by the manifest except as noted in Item 14a", P�ntedrryped Name 1 SignatureJ` onth 5 y, Year EPA FdW6M0-22 (Rev. 3-05) Previous editions aFebbsolete. Y Z DESIGNATED FACILITVTO GENERATOR