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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS 1, Generator ID Number (g } 'T 2. Page 1 ofj 3. Emerger?c! t,-fy"SM4n5 2l o 4. Manifest Tracking Number r <br />WASTE MANIFEST 3 G B F <br />5. Generators Name and Mailing Address L-Ttif'ied Grocers, Inc. Generator s ���ejs (P c�E rn�t� S mVi @ address) <br />:\teAtict1: Dmtcymr.ental 'Health & SWterj 1941? Pie c,li Rotxi <br />5 zo() ,5iltila SITwLt i. ommc-r -c Ca. 90040 Stockton, ca9'`'1 1 � . <br />Generators Phone:(= ") -.764 �``00x864i <br />6: Transporter 1 Comp m U.S.EPA Nu r <br />a9 fvt'g01t fjftt�- c�rt�lin °t <br />7. Transporter -2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Addr a �• U.S. EPA ID Number <br />s ty rvt Joaquin Parker r 4�aci11 <br />t._r-U- lt)6 i o2l I <br />Facility's Phone: <br />ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 Total 12. Unit 13. Waste Codes <br />HM and Packing Group (if any)) No. Type Quantity Wt.Nof. <br />pf?" <br />UAI <br />ul <br />ZI 2. _Dl <br />(D T <br />R1 Ctyl <br />3. <br />E <br />J <br />14. Special Handling Instructions and Additional Intormanon t r } r <br />? l ` li�f�fii,s. } t. Lt ;:C° (._ k".v.iXed Oii *.Ailprt)pri.t, et'*st?i1:ai "it3ty�tlS'e <br />Eq1;11[D.tT ent <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 ott onsent. <br />I certify th4lle waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) of'(b),(if I am a small quantity generator) is true. <br />Generator s!0 �rar Printed/Typed Name Signatur Month . • Da Yf <br />Ivo (, <br />—J t6,International Shipment s <br />~ ❑ Import to U.S. El Export frorS. Port of entrylexit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />W 17. Transporter Acknowledgment of Receipt of Materials <br />W Transporter JPrjntedlTyped t , Signa)ur `, Month - /Day it <br />O/! t(( �( `' t 5 CL1 <br />t Month Day Y <br />Q Signature <br />Transport r 2 PrintedfTyped N2the t <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantity ❑ Type ❑Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />181b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Facility's Phone: <br />w 18c. Signature of Alternate Facility (or Generator) Month Day <br />—_ <br />z <br />H19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 51' <br />01 <br />2 3. 4• U <br />. . <br />20. Designated Facility Owner or perator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Month Day Year <br />Printed(TypedName Signature _,.---- <br />