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016r;nrn: n.. in !P: rm ieernncrr fnr iicp nn plitp (19-nitrh) tvnpwritpr 1 Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />Page 1 of <br />3. Emergency Response Phone <br />4, Manifest Tracking Number <br />1 0 0 ? JJ K <br />WASTE MANIFEST <br />C A D 9 8 2 5 0 8 2 5 1 <br />1 <br />9.$89,5607 <br />5. Generator's Name and Mailing Address generator's Site Address (if different than mailing address) <br />Unf3ed Grocers Unified Grocers itf_ <br />Attn: Pat GULarrrtety, 52COG Shelita Street 1990 Ficccl Rd. <br />Commerce CA 90040 Stockton CA 95215 <br />Generators Phone: .II <br />4 ') _ F " S± <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Haz flat Trans, Inc. IC A T 0 8 J 0 1 2 8 0 0 <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 />Crosby & Overton <br />1630 W. 171h Street <br />LW9 Beach CA 90613 <br />A P.. 0 2 8 4 0 9 0 1 9 <br />Facility's Phone:C <br />9a <br />9b. 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 />X <br />�N1950,WASTE Aerosols/ <br />_ <br />z <br />1331 1343 <br />2.1 (aerosol) <br />/ <br />09+r. <br />S d <br />P <br />Z <br />2. <br />LU <br />AfrI <br />3. <br />AL <br />4. Q <br />ENVIRONMENIALM <br />{ <br />LTM <br />14, Special Handling Instructions.and Additional Information <br />51192 FR.G126����� <br />9b.1.) Aerosol Profile# <br />Gloves & Goggle-- <br />oggles15. <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 classed, 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 EPAAcknowledgment 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) ('rf I am a small quantity generator) is true. <br />Generatoes/Offeroes Printed/Typed Name Signature Month Day Year <br />16. International 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. TransporterAcknowledgment of Receipt of Materials <br />Tran porter 1 Printe ped Name Signature r MonthDay Year <br />/ � / <br />f "'7 �! <br />��qq � <br />i /4-'G' 4"t -1 %r <br />zQ <br />Tra sporter 2 PrintedlTyped Name Signature Month Day Year <br />tY <br />F- <br />NJ <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />WAS RF.CEIvED, tlaNULED AND.SiURFD FUR SUBSFqWADEenceNumber. <br />18b. Alternate Facility; o GgAgra� r mo,T OR R ,:iF- UKU U.S. EPA ID Number <br />qNT OF TOXIC SUBSTANCE CONMOI, TOGS <br />GXA,+fl il) TO n'L%'. BY 11, DE�'ART' <br />ACCORDANCE N nE PROVIISB)NS OF <br />r�i 1T i8 QIVIROyMF:VTA1. pROTG(TION AGENCY W W'TI <br />na NEMS�Y <br />LL <br />Facility's Phone: lZCE RE;OURCE CONSERVATION A111) RECOVE11ftYL OVERTON HASH OP <br />w <br />18c. Signature ofAltd=I1 A� o f4 �NCFD WASTE AND ALLMXMXM <br />Month Day Year <br />Q <br />Z <br />A (,'CORDUI0.Y <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C <br />1. <br />HI <br />2. 3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name r <br />Signature Mon <br />Day Year <br />