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Plpasp nrint nr tvne (Fnrm riasinnad fnr use nn elite (12-13itrh) tvnewhtpr 1 Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR UNIFORM HAZARDOUS V 1. Generator ID Number T2.Pegelof 3. Emergency Response Phone anifest Trackin Number 7009760026JJ K WASTE MANIFEST C A D S 8'2 . ,. „jW9,*9.N07 $ 2 5 1 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Utifled Grocers Unified Grocers AM: Pat G:ilse iety, 5200 Sheila Street 1990 Piccoll fid. Comerce CA 90M Stockton CA 95215 Generator's Phone:_i 6. Transporter 1 Company Name 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 Crosby & tvertcn 1630 W. 17th Sheet Lwg Beach CA 90813 Facility's Phone: a _ s5 L A D 0 2 8 4 0 9 0 1 9 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. IttUN1950, WASTE Aerosols 1 1331 S43 W2.1 DM 5 ✓' P W w r, 2. RERC I 3. JUL 2314 4. ENVI ON EN ()EPA111 1-1 14. Special Handling Instructions and Additional Information 9b.1) aerosols - Profile #51192 ERG #126 Gloves Goggles 15. GENERATOR'S/OFFEROR'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 EPAAcknowledgment 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)Js true. Gene a is/OfferorsP ' ted/Typed Name Signatur' Month Day Year -j F- 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: z Transporter -signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials` Ir Transporter 1 Pdnted/Typed Na7 Signature Month Day Year s �a 2- < Transporter 2 Printed7Typed Name sir Signs re Month Day Year f- 18. Discrepancy t' 18a. Discrepancy Indication Space ��oouuanti ❑Type ❑Residue ❑ Partial Rejection ❑ Full Rejection IfH It ICEb WASTEIVAS CEIVFD, HANDLED AND STORED FOR SUBSEQUENT OFnrTE b11POIAL, TPAATMENT OR REUSE CROSBY A OVERTON, INC. OPERATES THE FACT IY UNDER i,F,IkMTTS c1RANM TO TIIKK BY 7Ht7. DEPARTAW-NT OF TOXIC SUBSTANCE CONTROL Ttl ference Number: 18b. Alternate F i i ^ ' A WITTI THE PROVISIONS OF U.S. EPA ID Number i' t}llitCE NSMkVATION AND RECOVERY ACT Or 1976 TOG'EI7ifR %TM APPLICAgU U 11MUL AND STATE REGULATIONS, I.RUSBY A OVERTON HAS ALL OF TFrE NECESSARY LL TO ACCEff nM REFERENCED WASTE AND ALL THE WASTE HAS BEEN HAMM Facility's Phone := W 18c. Signature of Alternate Facility (or Generator) l 'Month Day Year Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) G L s( 2. 3. 4. d Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest exp! t a Item 18a FPonrtName Signatur Month Day Year 0 Ir,��,-----------�-~-� o�� ; EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR