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.i,+ - h,no /Fnrm desinned for use on elite (12-oitch) tvoewriter.) <br />Form Approved. OMB No. 2050-0039 <br />VY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of3. <br />Emergency Response Phone <br />4. Manifest Tracking Number <br />90760%3`733 JJ K <br />WASTE MANIFEST <br />C A D S 8 2 5 0 8 2 5 1 <br />1 <br />sss•5so7 <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Unified Grocers UtMfled Grocers <br />Attn: pat Gt:iilermety. 5,200 Shelia Sheet 1990 F4c--cA Rd. <br />Commerce CA 9CM dctcn CA 95215 <br />Generator's Phone: I ? 1 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Haz. Mat Trans, Inc. IC A T 0 8 0 0 1 2 8 0 0 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Slemen'sl�ti�-fa,. r'�',1!.��J 1� l <br />5375 SWM B`O* Ave. <br />Ven = CA 90058 <br />ICAD09703 0 9 9 3 <br />Facility's Phone: 7 <br />ya <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />0 <br />1Non-RCRA, Hazardous Waste Solid <br />(Oily debris)D{v1- <br />W <br />3. <br />REC1E1'V1:;LJ'J <br />4. <br />JU <br />28 <br />14. Special HandlinglnstructionsandAdditionalInformation {� E-WRQNMENTAL HEALTH <br />9b.1) Oily Debris Profile#AP168384 <br />9b . 2 i- kRTMENT <br />Gloves & Goggles, / <br />X <br />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, <br />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 <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />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. <br />Generators/ff or's Pnnted/T d Name Signature Month Day Year <br />f r� �� 21- <br />-J <br />16. International Shipments <br />❑ Impart to U.S. Export from U.S. Port of entry/exit: <br />F-- <br />z <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />O <br />Transporter 1 Printed/Typed Name Signature i Month Day Year <br />/ l <br />,✓ <br />Q'Transporter <br />2 Printed[Typed Name Signatur Month Day Year <br />F- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />C.) <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />z <br />F) <br />19. Hazarddhp Wastq Report Management Method Cocies,(i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or 0 erator: Cert fication ofr.eceipt of hazardous materials covered by the manifest except as noted in Item a / �% - <br />Printedffyped Name Signature r Month Day <br />/Year <br />tt'A Form 8700-22 (Rev. 3-05) P�reviou5 editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />