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Please pr t or type. (Form designed for use on elite (12 -Ditch) typewriter.) I I r\tlFll V VCU. VIVID I YU. LV V V'V UJ,i UNIFORM HAZARDOUS 1. Generator ID Number 2. Page`1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST C A 0 9 8 2 6 0 8 2 5 1 1 9.889.5807 - ��7�' 9� i9JJ a.+ N s. 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) Unified Grocers Unified Grocers Attn: Pat Gullermety, 6290 Sheila Street 1990 Pi+ccoll. lid. Caw-nerca CA 90040 Stocictar. CA 96215 Generators Phone: 3 2 3 2 6 4 - 5 2 0 0 6. Transporter 1 Company Name U.S. EPA ID Number Diaz Mat Trans, Inc. C A T 0 8 0 0 1 2 8 0 0 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number Crosby & Overton 1630 W. 17th Street Long .Beach CA 9''0813 Facility's Phone: 432-5446 C A rJ 0 2 8 4 0 9 0 1 9 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) Quantity Wt.Nol. 13. Waste Codes No. Type od»d i bN1960, WASTE Areroscis X 2.1 331 � 3433 ' I I DM 3. M i 4. 14. Special Handling Instructions and Additional Information DEPARTMENT ,y , r 9b.2) Aerosols Profile# 5119'2/ERG126 �1° L' 12-4 1 GLOVESS & GOGGLES 15. GENERATOR'SfOFFEROR'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, 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 Exporter, I certify,that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) ('rf 1 am a small quantity generator) is true. Generale Offerors Print9iTyped Name Signature /)f Month Day Year V N1 Mr) J F-- 16. Interna conal Shipme is ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: W17. Transporter Acknowledgment of Receipt of Materials OTransporter C. 1 Printe yped Name Signaturg, Month Day Year PW Q Transporter 2 PrintedlTyped Name Signator Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space Quantity El Type El Residue ❑Partial Rejection El Full Rejection -.aEXENCED %AStt. w•AS nc(tirvkb. rtAVULLD ANU STURW FUR YUBSNUENT Ot r1l: !x•u. TREAMtENT OK RELSE. CRUSBr A OVENTON. INC OPERATESLnV tiNffa Reference Number: 18b. Altemate FacilVbP3699 1)TO n1EM. BY TIM DEPARTMENT OF TOXIC SUBSTANCE CONTROL. T0GET}" U.S. EPA ID Number J :tit ntE ENVIRONMIEYTAL PROTECTION 1kGFNCY IN ACCORDANCE WnW IM pROVLSIONS 0I (j rrt: RESOURCE CONSERVATION AND RECOVERY ACT OF 1976 TOGEn= WfM APR.ICAII AND STATE REGULATIONS. CROSBY A Ll Facility's Phone',DCRAL OVFRTON HAS ALL OF TTS NP, WSARy In Q 18c. SignalurgpfWfLapility (or Generator) Month Day Year Z N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1• 2• 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Namerr rr i Signatu Month Day Year G:' c,, i FPAFnrm Q7n A Oo 10— 1 nr% n._..;,,, ,,, _a;Q.,..., ..._ _I,__I_._