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'1 - <br />Planca nii„t nr h/ne' (Fnrm designed for use on elite (12-nitcnI tvoewriter) .., Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS J <br />i. Generator ID Number- <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />1005400951 JJ K <br />WASTE MANIFEST <br />C A Q 9 8 2 5 0 8 2 5 1 <br />1 <br />9.889.5807 <br />5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Urifled Grocers Unilled Grocers <br />Attn: Pat GU1erinety, 5200 Sheila Street 1990 Picccd Rd. <br />Commerce CA 90040 ecicton CA 95215 <br />Generator's Phone: n <br />/e <br />a - 2 9 9 U.S. EPA ID Number <br />6. Transporter 1 Comp9nylVa <br />Naz Mat Trans Inc. IC A T 0 8 0 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 & Colinton <br />1630 W. 17th Street <br />., <br />Long Beach CA 90813d a <br />Facility's Phone: ., <br />ga, <br />9b. U.S. DOT Desci tion (including Proper Shipping Name, Hazard Class, ID Number, <br />P • (• 9 P P • 9 <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 />ce <br />t. <br />UN 1950, WASTE Aerosols <br />XQ1 <br />331 343 <br />I. <br />X <br />2.1 (aerosols)DM <br />S <br />Z <br />2.Rl=r,r=71X <br />n <br />W <br />3. <br />.. <br />JU <br />28 <br />EMIL <br />4. <br />ENVI <br />ONATIN <br />I <br />L HE, LTH <br />14. Special Handling Instructions and Additional Information <br />,3b. 1) Aerosols Profile# 51192 /ERG# 126 <br />�' rt " 1 I. <br />GLQVES & C,(X-;CiL$S <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 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) (if I am a small quantity generator} is true. <br />General es/Offeroes PJ tedffyped Name SignaturQ. Month Day Year <br />e S <br />ri <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />Li <br />17. Transporter Acknowledgment of Receipt of Materials • <br />Li <br />Transporter t PrintedlT�ped Name Signatula / � Month Day/ Year <br />Transporter 2 Pnnted/Typed Name Signa a Month Day Year <br />Q <br />Ix <br />, <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Li- RLT1'RJ;KED w'AS174 WAS KFL'Ii FV tiANOLAD AND ST==lutifW encs Number: <br />18b. Alternate Facili =611 TO'nILM. BY THE DFPARTIWENT OF TOXIC J Si;- -60—M, tOli 1 j1iFR U.S. EPA ID Number <br />-+ <br />-wI-Vi THF ENV1R0NMFMAL PROTECTION AWCY 10 ACCORDANCE r/nW TW PROVISV401 <br />V <br />114E RESOURCE CONSE tVATION AND RECOVERY ACT OF 1976 T009M wrm AMICANI <br />LL <br />Facility's Phone: tFDFJLU. AND STATE REGUIU71ONS, CROSBY A OVMTON HAS ALL OF TIQI NEMSARY <br />C3 <br />tBc.SignatureofAl cit ( atM WAM ` ' Month Day Year <br />a <br />;',nu Y <br />z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Pted/Typed Name Si natur r�1 M .,.'-- Month Day Year <br />rjng.,/�-�•!' � __ <br />tiF <br />