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WH(TE —ORIGINAL (Return to Generator) YELLOW —TSDF (Retain Copy) PINK —TRANSPORTER COPY GOLDENROD —GENERATOR'S COPY <br />NON-HAZARDOUS <br />1' Generator's US EPA 10 No. <br />2. Page 1 <br />3. Document Number <br />WASTE MANIFEST <br />pl <br />N° 10400 <br />4. Generator's Name and Melling Address <br />Unj;iedGrcrcprs <br />RECEIVEC1,990 <br />Piccaii Road <br />Generator's Phone CA9�7.?.5 <br />5. Transporter Company Name 6. US EPA 10 Number <br />7. Transporter Phone <br />Ian a EnvEs�rtrr ns, 1 S*'rtrir�s CAi Cc3 357�3 <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />8. Designated Facility Name and Site Address 9. US EPA ID Number <br />10, Facility's Phone <br />kon 1Ertvinrnn7ent;i! inc <br />?1r! -476-174C <br />pa<!d CAL CMJ 3691326 <br />G <br />Unir.1n City, CA 41557 <br />E <br />N <br />11. Waste Shipping New and Desch tion <br />g P <br />12, Containers 13. <br />14, <br />E <br />Total <br />No. pew Ouenti <br />Urht <br />1 <br />T <br />Non-Hazardous waste, liquid <br />✓ <br />O <br />a <br />b. <br />15. Special Handling Insinxtions and Additional Information <br />Handling Codas for WaAlas Listed Above <br />Ila. 11b, <br />C1ezn 1'-:h �nvironmenTai <br />16. GENERATOR'$ CERTIFICATION: I eerllty the matariafs described above on this manifest are not subject to state or <br />federalAIgulatians for reporting proper disposal of Hazardous Waste, <br />Printed/Typed Name I _ <br />%G' <br />Signature ,, <br />j <br />% i <br />7 <br />R <br />r % �i <br />l/- <br />Month Day yper" <br />A <br />w <br />N <br />S <br />17, Transporter ACtmowied ement of Receipt of Materials <br />0 <br />0 <br />Pdnted(Typed Name <br />Signature <br />lMourn <br />Day Yaar <br />R <br />18. Discrepancy indication Space <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />19. FaciRty Owner or Operator: Certification of recelpt of waste materials covered by this manitest axc'dpt as noted In ftom is, <br />PdnledJryped NAmA <br />Slonature <br />Month Day Year <br />WH(TE —ORIGINAL (Return to Generator) YELLOW —TSDF (Retain Copy) PINK —TRANSPORTER COPY GOLDENROD —GENERATOR'S COPY <br />