Laserfiche WebLink
Fnrm Annrnvpri nmR No. 2050-0039 <br />riedbe <br />pnnuvi iyNc. iF uini ucaiyncu <br />UNIFORM HAZARDOUS <br />- ... - -« r - 'cry---, <br />1. Generator ID Number' <br />2. Page 1 of <br />3t Emergency Response Phone <br />4. Manifest Tracking Number <br />1007695. �� 3 JJ K <br />WASTE MANIFEST <br />C .A D 9 8 2 5 .IO 8 2' 5 '+ <br />PW. 889.5,607 <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Unified Grocers U!•? W Grocers <br />Attn: Pat GL.IWrrnety, 5200 Sheila Lb�eet 1990 Piccol Rd. <br />Comma-ce CA 90040 Stockton CA 96215 <br />Generator's Phone: A I n r', <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Haz Mat Trans, Inc. CAT 0 8 Q U 1 2 8 0 G <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 />Veola E5 Tectricat SoUons <br />4.74 F- # 5.7 e ply <br />�r� C,L�i�41 <br />,qZL!&a-CA-944$ �rj'i✓I X r j TFJi7� <br />Facility's Phone% <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 />1UN3090, Litv+rt battery <br />dN• <br />' <br />I <br />----E.__.__--_..�. <br />X <br />9, PGIi <br />P <br />L <br />I• <br />3. <br />I <br />4. <br />ENVI <br />ON <br />ENT HE�LTH <br />14, Special Handling Instructions and Additional Infimation DEPARTMENT <br />9'r1} Battery �j �'�.^D <br />Glove3 & Gaggles �•-! !f // <br />15. GENERATOR'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 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,= a small quantity generator) is true. <br />Generator'sl roc's Printed/T ed Name Signature Month Day Year <br />u 1) e, 1: 15 <br />-J <br />F <br />16. Internationa Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />z <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />'Year <br />Transporter 1 Printed/Typed Name Signature /? Month Day <br />Qranspo <br />rintedrryped Name Signal y Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indican n Space 9,Quantity El Type l r' ❑Residue El Partial Rejection El Full Rejection <br />J1`/I�Ga1i'. jt✓)t, <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />V <br />LL <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 Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />� 1, 2. 3. 4. <br />-(\ <br />-H� <br />r20. Designated F DesignIffy Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except 0 noted in Item 1 Ba <br />Printedff Nae /t Signature J' Month Day Year <br />FCA Fnm, R7nn.99IRgv 3-n51 PrPviQUJ ej ijUpns are obsolete. ! nF,Jr-,RATFn FArIi ITY Tn nFNERATOR <br />