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Please print or type. (Form designed for use on elite (12 -piton) typewriter.) 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 R 2. Pagd 1 of r 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST CAD 9 5 2 5 0 8 2 5 1 11197 •8=19•5E0% 10 0 7 6 96) 5 S, JJ K 5. Generator's Name and Mailing Address z' }, Generator's Site Address (if different than mailing address) UrOled Grocer Uriified Grocers Attn: Pat GUBermty, 52CC) Sh6le Street 19M PIccod Rd. Crmrnerce CA 90040 Stockton CA 95215 Generator's Phone: 3 2 3 2 5 4- 5 2 0 0 6. Transporter 1 Company Name U.S. EPA ID Number Diaz 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 - - Cr6Sby-8 0446r#cti _ 1630 W. 17th Streit LoN Beam CA 90813 Facility's Phone:' 432-5445 ,✓ A 0 8 J 9 0 1 9a 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./Vol. Of X bN 1950, WASTE Aaer=b X01 1331 X343 0 2.1 (aerosols)om 5�0 P W 0 � �i 3. j. 4. 14. Special Handling Instructions and Additional Information 0EPAftTMENT Aerosols Profiles# - 51192- ERG: 126 _ Gloves & Goggles r 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 tabeledlplacarded, 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. Generat /0 eror's Print yped Name Signature Month Day Year z i1 ,6 --t P- 16. Int mational Sbipm6nts ❑ 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 j I-- Transporter 1 Printed/Typed Name Signature / Month Day Year ZZ Transporter 7 PrinfedlTyped Name Month Day Year 18. Discrepancy t' 18a. Discrepancy Indication Spacer El Full Rejection ❑ Quantity El Type 1:1 Residue ❑Partial Rete � �, -nM REFERENCED WASTE WAS RECEIVED, HANDLED AND STORED FOR SUBSEQUENT OFFSRE /✓ TES TELE FAcNft% RA*nce Number. It=186. Ntemate Facili D TO TFlE11. gy 7}� DEPART%ffM OF TOXIC SUBSTANCE CONTROL. TOGEI1ffJL U.S. EPA ID Number V Hf111 TLIE F1VVIRONMEt:TAL PROTzCTION AGENCY IN ACCORDANCE WITH THE PROVISIONS OF AND RECOVERY ACT OF 1976 TOGETTIIR WRH APPLICABLE LL lP RESOURCE CONSERVATION Facilitlls Phone: r-TDERAL AND STATE REGULATIONS. CROSBY & OVERMN HAS All. OF THE NECESSARY W 18c. Signature of Alteti18t9fMiIi1IA to CEDMonth Day Year Q 4CCORDINGLY Z L' 55 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) C 1. 2. 3. 4. ted Facility Owner or Operator: Certification ofreceipt of hazardous materials covered by the manifest except as noted in Frntds/Tyrp"edName .--, Signature/ Month Day Year 1 / f Mi..1 •F I^ EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR '?'