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Please print or type. (Form designed for use on elite (1`2 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 EP orm 00-22 (e . 3-O) revious itions re ole e. D SIGNATED FACILITY TO GENERATOR UNIFOR HAZA 'OuS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone -W,07 1 4. Manifest Tracking Number 009760028 JJ K WASTE MANIFEST C A D 9 8 2 5, 0� 2 8 119109.48q.. 5. Generator's Name and Mailing Address - Generator's Site Address (if different than mailing address) Unified Grocem Unified Grocers Attn: Pat Guillennety, 5200 Sheila Street 3 1990 Pick Rd. Commerce OA 90040 StoCkton CA 95215 Generator's Phone: 3 2 3 2 6 4- 5 2 0 0 6. Transporter 1 Company Name X U.S. EPA ID Number Haz Mat Trans, Inc. IC A T 0 8 0 0 1 2 8 0 0 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number NMenrloXerdoon 2000 N. Aiarneda Street CoTVon CA 90222 Facility's Phone: 310 537-7100 L d! t U$ 0 1 3 i 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 Group (if any)) Quantity Wt.Nol. 'Non-RCRA HazardWS Waste Liquid 221 0 c�q T -P T__._ CD THIS ',VASTE STRP41 HAS BEEN Ql At 3. �. , :.,__� .t,..,yr ' -u +Ill COMPTO N ,� •r, :,�a. uL Tr�t:rr�n1lEM SARY I 4. et i'ljii lt; ; z,_Ofi-'UvlsVY''kJlf_ -tA ,Q QUALIFIED. OURE.'A tiU118 -R IS CAT080013352 i ---- I F EALV RO MEN AL 14. Special Handling Instructions and Additional Information �EPARTMEf�T 917.1} Oil. .3 X-T'r9Tc Gloves & Goggles 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 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 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. Ge ner forslOfferor's�j inted(ryped Name SignaUli 1' G1 v/�s- Month Day Year /3- -J IF- 16. International Shipments ❑ Import to U.S. El 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 R Transporter 1 Printedfryped Name Signature \ Month Day Year a 2- Transporter 2 Prin edfryped Name Signa Month Day Year ce H 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantityyp ❑ ElT e Residue Partial Rejection ❑ j El Full Rejection Manifest Reference Number. F- 18b. Alternate Facility (or Generator) U.S. EPA ID Number J L) u- Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 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 . Printedr r ped Name #-- Svature- �. Month Day Year EP orm 00-22 (e . 3-O) revious itions re ole e. D SIGNATED FACILITY TO GENERATOR