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asF�e orin or tvoe. (Form desioned for use on elite (12-nitchl tvr,owritor ) C...... A..... -..-J AIIr] EPA Form 8700-22 (Rev. -05) Previous editions are obsolete. V Y UNIFORM HAZARDOUS 1, Generator ID Number 2. Page 1 of 3. Emergency Response Phone •rr• 4. Manifest Track' Number WASTE MANIFEST C A D S 8 2 5 Q 8 2 5 1 1 sa•.607 0 D® JJ K 5. Generator's Name and Mailing Address Urlified Grocers Generator's Site Address (if different than mailing address) Urvfled-Grocers Atfi: Pat Guittermety, 5200 St*da Street 1990 r iccdi Rd. Commerce CA 90040 ZA 9.5215 Generator's Phone: 3 2 3 2 6 4- 5 2 0 0 6. Transporter 1 Company Name U.S. EPA ID Number Haz Mat Trans, Inc. C 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 Siemens Industry. Inc. U.S. EPA ID Number 5375 ScUdi Boybe Ave. Vernon CA 90058 Facility's Phone: 800 266-77.47 IC A D 0 9 7 0 3 0 9 9 3 9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) Quantity 13. Waste Codes Wt.Nol. No. Type "Norm-RCRA, Hazardous Waste Scald �r2 0 DM P z 2. to R E= CaN E -J *14V ED -w 3. UL 2 1 4. NVIR® ME L EA L H _ SPA MET 14. Special Handling Instructions and Additional Information 9b.1) oil/absorbent - Profile, #AP168384 Gloves & Goggles X ter' �1 1�� '•�"--� 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) is true. Geff toes/Offero Printed/Typed Name Signature Month Day Year + M OW Lo Z 16. International Shipments Import to U.S. 1:1❑Export from U.S. Pod of entrylexit: Transporter signature (for exports only): Date leaving U.S.: w 17. Transporter Acknowledgment of Receipt of Materials tE Transpo r 1 Pdnted//T�ped Name Signature Month Day Year Q ransporter 2 Printed/Typed Name Sign re Month Day Year F 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quant Quantity ElT e Type El Residue ❑Partial Rejection El Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J .. V Facility's Phone: W 18c. Signature ofAltemate Facility (or Generator) Month Day Year Q Z U- 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) p 1, fir 2. 3. 4. 20. Designate FacilityOwne or Operator: Certifiealion of re t of hazardous aterials covered by the manifest except as noted in Item y6a Pdnted(fypedName Signature % Month I Day Year EPA Form 8700-22 (Rev. -05) Previous editions are obsolete. V Y