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Pleas t F rm dei ned for use on elite (12 -pitch) typewriter) <br />Form Approved. OMB No. 2050-0039 <br />Fan P— aWnn_Y) (PAv I-nM1 Previnrrs Aditinns are obsolete. a nFctr,1,t ATFn t=nru 1TY Tn r,FNFRATnR <br />e pnn or type. (o s g <br />UNIFORM HAZARDOUS <br />1. Generator ID Number . <br />2. Page 1 ofF;ncy <br />Response Phone4Manifest <br />Tracking Number <br />00769J.3447 JJ K <br />WASTE MANIFEST <br />0 A D 9 r3 2 5 C 8 2 5 1 <br />� <br />.560 <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />1nfled GMCers t trifled Grocers <br />Attn: Pat GIfermeity, 32£O SYalta Str"t 1990 PlccrA Rd. <br />COrnmterce CA 90040 Strckt©n CA 9521 <br />Generator's Phone: •q ? 1 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Haz Me Trans, Inc. C A T C 8 C 0 1 2 8 0 C <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Facility Name and Site Address U.S. EPA ID Number <br />darer Water'Technok4es Corp <br />5375 South So* Ave. <br />Vernon CA 9CO5$ G ;, D 0 9 7 f 8! 9 5 ;s <br />Facility's Phone: s <br />9a <br />91b. 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 />1Non-RCRA Hazardous Waste Sold <br />i <br />35201 <br />(dVabsorbent) <br />um IL��C <br />i <br />•) <br />Z <br />UJ <br />2. <br />�•, <br />3. <br />I <br />I <br />JU <br />L Id <br />4. <br />ENVI <br />ION <br />ART W-- <br />-14. <br />14.Special Handling Instructions and Additional Information <br />9b.1) 0i1 absorbent profile# AP16838,1 <br />Gloves & Goggles <br />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, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemational 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 terns 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 />Generat e Offeror's Print yped Name Signaturo- Month Day Year <br />0 <br />-J <br />i- <br />16. International Shipme is <br />❑ Import to U.S. ExP ❑ ort from U.S. Port of entry/exit <br />K <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />Ll <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />�/ <br />a—'!e! <br />�✓-' <br />M <br />Trod�ansporter 2 Printed/Typed Name Signature Month Day Year <br />Q <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ ouanfity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection •C <br />Manifest Reference Number: <br />181b. Alternate Facility (or Generator) U.S. EPA ID Number <br />L) <br />9D <br />ITEM 0 <br />W <br />Facility's Phone: <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Wpste Repq f.Management Method Codes (i.e., codes for hazardous w treatment, disposal, and recycling systems) <br />w 1 2. 3. 4. <br />z <br />i <br />20. Designated Facilly Owlle"t or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a r <br />Pri a ed Name ,,1 Signatu eMonth r Day Year <br />Fan P— aWnn_Y) (PAv I-nM1 Previnrrs Aditinns are obsolete. a nFctr,1,t ATFn t=nru 1TY Tn r,FNFRATnR <br />