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oir me t% -n (Pnrm r1acinnod fnr i iso nn alite f 12-nitchl tvnewriter.) Form Approved. 01VI8 No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />DESIGNATED FACILITY TO GENERATO <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />A <br />2. Pae 1 of 3. Emer enc Response Phone <br />4. Manifest Tracking Number <br />lk <br />1 00769,E115-79 JJ K <br />WASTE MANIFEST <br />v A D 9 8 2„ n 8 2 5 # <br />iP09.389.5807 <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />ut�itled grocers U i led Grocers <br />Atm: Pat GUerT *N. 520,0 Sk?eft '87t�et 19W Piccd Rd. <br />Commerce CA 90040 . Stockton CA 96215 <br />Generator's Phone: 3 2 3 2 6 4-.._ 5 2 4 0 <br />U.S. EPA ID Number <br />6. Transporter 1 Company Name <br />Naz heat Trams, Inc. C A T d 8 D l3 ! ' 8 0 C) <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 />Siemens Water TeCIrdogies Corp. - <br />5375 Saint 33oyte Aire. <br />Vernon CA 90068 C A D 6 .9 7 0 3 0 9 9 3 <br />Facility's Phone: 8W 266-7747 <br />9a <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />t <br />bion-RCRA, Haz'ardWS Waste Sold <br />(oiliabsor5ent) <br />EIN <br />352o <br />jJ <br />� <br />,t lr{�1 <br />�J 1 Z' <br />I <br />Z <br />LU <br />2. <br />_ _.4--. <br />C7 <br />i <br />3. <br />till" <br />4. <br />�+ <br />ENVIRONMENTAL. <br />HEA TH I <br />14. Special Handling Instructions and Additional Information IEP <br />9b. 1) Oil Absorbent Prefile#AP168384 <br />Gloves & Goggles <br />& � �r / <br />15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by tire 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) (it am a small quantity generator) is true. <br />reslores Printed/Ty d NameQ 1 f Signature f Month Day Year <br />� �l.J 1. l 0ti YU ,--) <br />—J <br />16. International Shipments Export from U.S. Port of entry/exit: <br />❑ Import to U.S. ❑ <br />z <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />a <br />%rt <br />Trans orter 1 PrintN/Typed me / q Signature i •. Month Day Year <br />QTransporter <br />2 Phnted/Typed Name Sig re Month Day Year <br />tY <br />F- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue: I ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Ntemate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />D14 <br />ear <br />a <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C <br />i• � <br />2. <br />3• � <br />20. Designated Faci'ty Owner r Operator: Certification of rec t of hazardou materials covered by the manifest except as noted tri Ifem 18a <br />Printed/Typed NameSignature „ : — / Month Day Year <br />tit -.t <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />DESIGNATED FACILITY TO GENERATO <br />