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Please mint nr tvne. (Form desinned for use on elite (12 -pitch) tvoewriter.) <br />Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />CD982708231 <br />2. Page 1 of <br />1 <br />3. Emergency Response one <br />(323) 26--5200 <br />4. Manifest Tracking <br />000806244 Trackiing Number <br />D F <br />WASTE MANIFEST <br />` <br />5. Generator's Name and Mailing Address _ Generators Site Address (if different than mailing address) <br />United Groccrs, Inc., 1. riffie-d &overs, hie,. <br />Attenki')rt.; "�n?isrrurte,�tu HNndh & Safe / 1)00 Paoli Road. <br />yt Ca. 9521 <br />3200, `?h i Stec Comirie:rWe C�:. MAD Stockton. <br />Generator's Phone:. . <br />6. Transporter 1 Corti U.S. EPA ID Number <br />San loaginn Fitt-er .RtxyQ in C t.(}c7iJ 7 ti)? 1 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address r tv -- - = -U-S-EID Number---- <br />umber---'---i; <br />14,287,14E. <br />8"u. _ bnrzi ParliQr. a:_'«. 936411", <br />Facility's Phone: ' <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />it. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wtivol. <br />1. N t N Hazardow W"aste;, <br />221 <br />Liquid ,'sed Oil," Mixed Oil) <br />1 <br />TT <br />-5rO <br />r <br />z <br />2. <br />LU <br />c� <br />E%J <br />3. <br />_ I <br />V <br />vti <br />4. <br />EN <br />IRO <br />MEN AL H <br />14. Special Handling nsI and Add" n Inf on MENT <br />TR 9%i i` � - Pro ily #9B 1: Used Oil/N xed Oil '`appropriate; Personal 99A� <br />Equipment <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment arefullyand 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 am a small quanti generator) is true. <br />Generators/Offerors Printed/TypedName / Signatu er� Month Day Year <br />Ni 1 t<o AfLC..- 9 <br />(fi/� is j' l <br />_J <br />16. International Shipments <br />❑ Impart to U.S. ❑ Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />li <br />Transporter i Printed/Typed Name Signature r Month Day Year <br />QTransporter <br />2 Printed/Typed Name 7Sgnature Month Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />V <br />LL <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />Z <br />us19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />UJI <br />1. � iJ <br />2. <br />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[Tyged Name Signature Month Day Year <br />