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NON -HAZARDOUS 1 Generator's US EPA 1D No, <br />WASTE MANIFEST <br />4. Generator's Name and Malling Address <br />Grocers <br />1990 R iccoii Road <br />Generator's Phone Sto(:kton, CA 9,,;7, s <br />S. Transporter Company Name 6. US EPA 10 Number <br />�cn Eflvirtl�imer,al S�^rfice� CAL 000 362 980 <br />e. Designated Facility Name and Site Address 9. US EPA ID Number <br />Iran EIVironmf., tat Service inc <br />12.7 0 Wh;pp le Rom CAL OrDO 360 0'6 <br />G U-I;Ort Ci«f, CA 94587 <br />E <br />N 11. Waste Shipping Name and Description <br />E <br />R a <br />T Non -Hazardous waste, liquid <br />0 w `� <br />b. <br />1 1$. Special Handling Instnrct(ons and Addlt cnar Informatlon <br />2. Page 1 3. Document Number <br />of NY 10455 <br />RECEIVED, <br />JU <br />7. Trannporler Phone <br />ENVIRONMENTAL HEA TH <br />10. Facility's Phone <br />510-475.1 ?.C. <br />12. Conialners 1 13. <br />,5C. <br />Handling Codes for Wastes Listed Above <br />I <br />11 a, 11 b. <br />.r <br />Clean, Tech Enviranl-rental <br />1E3. GENERATOR'S CERTIFICATION: I certlfy the materiais described above on this manifest are not subject to state or federal reputations for reporting proper disposal of Hazardous Waste. <br />PrinledrTyped Name i Signature "` <br />A 1 Month Day Year <br />N <br />SS 17. Transporter Acknowledgement of Receipt of Materials <br />HPrinted/Typed Name Signature <br />T <br />E I`= Month Day Ymr <br />R f <br />18. Discrepancy Indication Space <br />F <br />A <br />C <br />1 <br />L <br />T <br />Y 19. Faclljty Owner or Operator. Certification of receipt of waste materials covered by this manliest except as noted In Item 18_ <br />Prinf4dfTyped Name i Signature <br />Month Day Year <br />WHITE —ORIGINAL (Retum to Generator) YELLOW —TSOF (Retain Copy) PINK —TRANSPORTER COPY GOLDENROD —GENERATOR'S COPY <br />