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Please print or Form Approved. OM8 No. 2050.0039 <br />p type. (Form designed for use on elite (12 -pitch) typewriter.) <br />1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />UNIFORM HAZARDOUS #rl;y ? { }yt � =.1 i . 1•3 x,31 -264—'' ytfl)'� <br />WASTE MANIFEST <br />GB <br />5. Generator's Name and Mailing Address Generator's Site Address (f different than mailing ad ess <br />• L.'<t,4-1-ed Grocers. Inc. M1 <br />C nitit~sd GTO( rs, 17?c- <br />Generators Phone <br />lJ S: EP kID Number, <br />6 Transporter <br /><,,qn oaqu Fiat& s talt=i Lt <br />U.& EPAID Number <br />7. Tran sporter2 Company Name <br />" <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />1.1287 E. ManningPafiier- CA. 936=18 <br />(;;� X98-0 � C AL000102 7 51 <br />Facility's Phone: <br />ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, c 10. Containers 1]uantily <br />12. Unit 13. Waste Codes <br />HM and Packing Group (if any)) <br />No. Type Wt.N01. <br />3, 1 <br />2)t <br />Liquid ( :sed Oi.L 4lixod'3i1)�r <br />00% <br />cw7 I,* <br />■L, , <br />3. <br />JUL <br />14. Special Handling Instructions and Additional Information <br />NAER.Uµ 9B1 171.* Profile µ9B1: 1-7. t-?il'Nlixed Oil �' ,��rlapiiate Personal Protective <br />Equipment. <br />15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shippingname, 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 exp ort shipment and I am the Prima <br />ry <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAckriowledgment of Consent. <br />I certify that the waste m imitation statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I a small quantity generator) is true. <br />Month Day <br />emotional Shipments ❑ Import to U.S. ❑Export from U.S. <br />Tr ns Amer signature (for exports only): <br />W17, Transporter Acknowledgment of Receipt of Materials <br />Trans er 1 Printed(fyped Name S' ure <br />CL <br />_ ..__� . _ Signature <br />Port of entry/exit: <br />Date leaving U.S.: <br />Month Day <br />Month Day <br />18. Discrepancy <br />18a. Discrepancy Indication SpaceQuant <br />❑ity ❑ Type ElResidue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />U.S. EPA ID Number <br />F>'„ 18b. Alternate Facility (or Generator) <br />J <br />U <br />LL Facility's Phone: Month Day <br />LU 18c. Signature of Alternate Facility (or Generator) <br />Q <br />Z <br />N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU 1 Z. <br />3. 4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day <br />PHaterIfTyped Name <br />Yea <br />