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Please print ortvoe. (Form designed for use on elite 02=o,whl-tvuewriter.) Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR UNIFORM HAZARDOUS 1. Generator ID Number Page 1 of 3. Emergency Response Phone 4., Manifest Tracking Number �[ 0 0 7 6 9 6 7? K WASTE MANIFEST C A O 9 3 2 5 0 2 5 1 1 <• 9•uS07 ;,i rJJ 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) Urlifled &ocerS Urilfed Grocers Ath: Pat GUIIIer mtY, 5200 Sheila Street 1990 P',CC-J Rd. Carr woe CA ` 0040 Stockton CA 96215 Generator's Phone: A 9 +1 6. Transporter 1 Company Name _ . U.S. EPA ID Number 141st Trans, Inc.:!`� 81 " 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 U.S. EPA ID Number Crosby $ Overton 1630 W. 171tt Street L,NV Beach CA90813 Facility's Phone: Ci��?28d09Q 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 if an 9 Grou p ( y)) Quantity Wt.Nol. o1 bN19150, WASTE AerosoiS 831 � � 343 _ _ _._. _ _.--- 9 / om P LU 2. 1 w OIL — r 3. !wimim j f 4. 14 Special Handling Instructions and Additional Information " 1�� 9b.1! aerosols Profile#51192 fr ERG:12% /� Gloves & Goggles �. �^ " ``► L 15. GEN ERATOR'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 1 am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 1 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. Generatofferoes Printe ped Name Signatur Month Day Year r 1 1 a CJ / —1 F-- 16. International Shipments . ❑ Import to U.S. El Export from U.S. Port of entry/exit: Z Transporter signature (for exports only): Date leaving U.S.: Of 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/typed Name Signature 4 Month Day Year 0 CL _ aranspo er 2 Printed/Typed Name Signat7 Month Day Year f- 18. Discrepancy 18a. Discrepancy Indication Space ❑ quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection ,11CE REFEREINCED WASTE WAS RECEIVED. HANDLED AND STORED FOR SUBSEQat I1FlIT eference Number: 18b. Alternate FgdKggr G r h U.S. EPA ID Number GRANT TO TI (EM, BY THE DEPARTMENT OF TOXIC SUBSTANCE CO1 L. TOGEItEIt J V ERNfI'S A'ritl T11E ENVIRONMENTAL PROTECTION AGENCY IN ACCORDANCE WrM THE PROVISIONS OF AND RECOVERY ACT OF 1976 TOGS 1,1ER WITH APPLICABLE Facility's Phone RESOURCE CONSERVATION qTATF TIONS. CROSBY d OVERTON HAS All OF TIE NECESSARY w 18c. Signature a cikttt&.Aerpto[�RENCED WASTE AND Month Day Year Q Z ACCORDINGLY �1 F) 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. i 7 , 2. 3. 4. 20. Designated Facility Owner or Operator: grtification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name l Signature mow: P Month Day} Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR