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5 _ a Form Aooroved. OMS No. 2050-0039 <br />urease <br />pnn[ or type. trorm uesiyneu <br />UNIFORM HAZARDOUS <br />wi use un cu to tic-Niu.iir ty puninoi.r <br />1. Generator ID Number <br />2. Page 1 of <br />I <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />005406952 JJ K <br />WASTE MANIFEST <br />C' A D 9 8 2 5 0 8 2 5 <br />1 <br />9.889.5647 <br />5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />Urgfied Grocer's Urified Grocers <br />Attn: rat GURemi?ty, 6200 Sheila Street 1990 Pict:d Rd. <br />C o:rowce Cry 913440 Stocldcn CA 95215 <br />Generator's Phone: 3 � 3 7 6 d - J '7 <br />U.S. EPA ID Number <br />6. Transporter 1 Company Name <br />C A T O$ 0 0 1 2 8 0 0 <br />Hoz Mat Trans, Inc. <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 />Siemens Water Techmicigies Corp. <br />5375 South Boyle Ave. <br />Vernon CA 9OW8 C A D 0 9 7 0 3 0 9 S 3 <br />Facility's Phone: ct <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 13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Ncl. <br />�or RCRA Hazardous Waste, SoNd <br />352 <br />0 <br />(diesel oiVd'irt/absorbent) <br />� <br />OM <br />"7� <br />P <br />Z <br />2. <br />UJ <br />c� <br />3. <br />4. <br />NTA HE I. <br />I <br />INVIF(FNM <br />DEIDAIRTM . <br />14. Special Handling Instructions and Additional Information <br />�?b.1i Diesel/oi/dirt/absorbent Profile# AP16838?4 <br />GLOVES & GOGGLES I�1-�t; <br />. <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 1 am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Gener tor's/IftlOffero PrintedlTyped Name Signatu l Month Day Year <br />J <br />j.. <br />16.1ntemabonal Shipments <br />Import 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 />/ <br />Transporter 1 Printed. yped Name Signature/ j Month Day Year <br />Trarfsporter 2 Printed/Typed Name Signa a Month Day Year <br />Q <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantity ❑ Type ElResidue ❑ Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />, <br />tJ <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />a <br />Z <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1, { 2. 3. 4• <br />20. Designated Faci)Ity (*her r Operator: Certification of receipt of hazy dbus materials c eAd by the manifest except as noted in Item 1 a i <br />PrintedlTyped Name/ r Signature / Month Day Year <br />'1 <br />/f <br />/ <br />-,4 '7�-,v, <br />T" <br />