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NO rI ARDOUS;WASTE MANIF <br /> Please print or type {Porto designed idr use on elite(i2 Qifch)typewriter) ` • - <br /> Manil�s[ 2.Page'l <br /> NON-HAZARDOUS 1.Generafoes US EPA ID No',.- Document No. <br /> WASTE MANIFEST <br /> D 9i�7. 503 251, '91.35of . <br /> 3.Gen eratoYs'Name and Mailing Address - <br /> UM fie3 ziestern Grocers -- A�tn: 1�at.Glail�e y <br /> .5200.--8F* . ' Street 9Q�J4fT <br /> Generators Phone( <br /> 323-264-5200- <br /> 4. <br /> 5.Transportei,t Company,Name - - 8. - US EFA 10 Number �s- .A.State Transporters ID <br /> Z , t' 5 'r - �T DPV 01.2 800 '.8:Transporter 1'Phone <br /> �Ja <br /> 7.Transporter 2 Company Name. .US EPA,fD Number. _ C.State Transporters ID -D.Transportar 2.Phone- <br /> 9.Designated Facility Name and Site'Addrass 10. US EPA ID Number E:S�asa Facility's ID Raw rely roriinesital <br /> 3210 E. .Fixontera..`fit [ F.Facility's Phone <br /> -Anar Im, ' �'�,. 923dG L 4fl0 ?40 50F}.:. :�23 2 � 5456 <br /> 12. Containers .-.-13 to <br /> 11".WASTE DESCRIPTION' - Total <br /> {{ Quantity <br /> 'No. Type -.. W1Nc1.-- .. <br /> �7- WARD0US 'ASM LZ' <br /> XTMS <br /> .b .. - <br /> G „ <br /> E <br /> Nr <br /> E R c. <br /> a. <br /> - - - - H.kandhng Codes for Wastes Usted'At�ove <br /> G Additierial'DescriplJorrs'for Materials L+sted Above , <br /> Horn--ha " wa <br /> FROF�LrE „04_; fig'-01 LID <br /> itional Information <br /> ' rudloru and Add iZlt . <br /> 'al Handliri�Inst 'k ��-.�� _ <br /> i5:SpeC g ... :-, ��1tE: $�QC.,tQr], � .r <br /> f.9.90.'Piecr�la,.'.R3. <br /> GiVG:5 rES Stcton, CA: 95215. <br /> R'S CERTIFICATION:I I rab'certify that the contents of]his shipment are full and accurately desorrbed and are rn a1SYespects'- _ <br /> ERATO n .. <br /> 16. <br /> .GEN - .. Y yy ste re ulall s - - - <br /> natsub <br /> ecl tofederal hazardous wa g - - <br /> _ .-.-. this manifest era. [ - <br /> . ,tri proper condrtioq for transport:The matofials described on <br /> `Date; <br /> Pnntedrtyped Nama Signal - - - Mon h y Ye <br /> -Date <br /> T <br /> .17Transporter 1 Acknoivledgemenf of Receipt of Materials-'- _ _ - - <br /> R Signator - Mo ba . Ya <br /> A <br /> -Pri a ad Name. -- <br /> (J <br /> � : pate <br /> P < 7. <br /> .O _ 18.Transporter Acknv edgement of Receipt of Mafenals ' <br /> nH .•(7a t Yea(.- . <br /> T ' Signature <br /> twonth, <br /> Y. <br /> T,,-;...PrintedlTypedName <br /> E': <br /> Ft <br /> i <br /> 19 Discrepancy Indication Space - - - <br /> _ 20Facility Owner or Operalor;'Certdication of receipt of thw <br /> e aste'malerlbls coveted try this manifest,exceptnotetl in item f9 <br /> Data <br /> -., Manih Day Year <br /> Signature <br /> t: PnntegTyped Name - <br /> r' y <br /> - Rev.3!95 <br /> F-tao2o5z V3E11"SASTFR019D0)621-s968 www.I balmastar.com �Pnrr1TED0Nr _'IxEpr+wER.( y rea.n <br />