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WHITE -ORIGINAL (Return to Generator) YELLOW-TSDF (Retaln Copy) PINK -TRANSPORTER COPY GOLDENROD -GENERATOR'S COPY <br />ALTH <br />NON -HAZARDOUS i1. Genarater'a US EPA ID No, <br />2, Page 1 <br />3. Document Number <br />WASTE MANIFEST <br />of <br />AL <br />4. Generator's Name and Mailing Address <br />UniFieca Grocers <br />REC,I.. <br />1"-490 Piccoli Road <br />Generator's Phone52ockton, CA 9521.5 <br />JUL 2 8 2014 <br />5. Transporter Company Name - 6_ .. - US EPA ID Number <br />7, Transporter P"T IR©N a q <br />�tV <br />Icon Environmental Senr(tes CAL 000 367 980 <br />1V1E���L HE <br />_^CLEARWATER-EiCViRaIMENTAL <br />(510) 476-17,QEPARTMENT <br />S. Deelgnated Facility Name and Site Address 9. US EPA ID Number <br />10. Faculty's Phone <br />Icon Environmental 5-ervices Inc <br />510-476-2/40 <br />122.0 Whipple Roars CAL 000 364 026 <br />Union City, SCA 94587 <br />E <br />N <br />11. waste Shipping Name and Description <br />12. Ccnlalnem 13. 14, <br />E <br />_,� <br />.No. TY Ova I V Wol <br />T <br />Non -Hazardous waste <br />/ f S J Q9 <br />O— <br />— <br />R <br />b. <br />i <br />16. Special Handling Irtstructlons and Additional Information <br />Handling Codes for Wastes Listed Above <br />Wear PPE <br />11a. 11b. <br />Emergency Contact <br />(510) 476-1740 <br />------- <br />Attn! Charles Seaton <br />Clean Tech Environmental <br />1 b. OENERAVR'S COMFICATION! I certify the mafarials described above nn this man6st are not subject 10 slats of federal reoutationS for reporting proper disposal of Hazardous Waste, <br />T <br />Printednfy Name <br />Signature <br />R <br />Month pay Year <br />A <br />/ <br />I <br />6 <br />P <br />IT Transporter Acknowledgement of Recelpt of Materials <br />O <br />Printedrlyped Name <br />Signature <br />T <br />'�",� . <br />Month D Year <br />18. Dlecmpancy ndlratlon Space <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />19. Facility Owner or Operator: Cenificatlon of receipt of waste materlala covered by thea mantfast except as noted in Item 1a. <br />PrInledflyped Name <br />Slgnahua <br />Month Day Year <br />I <br />WHITE -ORIGINAL (Return to Generator) YELLOW-TSDF (Retaln Copy) PINK -TRANSPORTER COPY GOLDENROD -GENERATOR'S COPY <br />ALTH <br />