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NON'.4AZARDOUS'WASTE MANIA_ST <br /> Please print or type {Form designed for use on elite{i2 pitch)Typewriter) <br /> NON-HAZARDOUS 1.Generator's US EPA JD No. Manifest Document No. 2•Page 1 <br /> WASTE MANIFEST CAD ,982 508 251 48741 of <br /> 3.Generators Name and Mailing Address - <br /> Unified Western Grocers - Attr..: Pat Gaillerinety <br /> 5200 Sheila Street, Ccir merce, CA. ' 90040 <br /> 4,Generators Phone[ 3Z3 264-5200 ' - <br /> 5.Transporter 1 Company Name 6. US EPA M Number A.State Transporters I D <br /> Haz Mat Trars, Trc. CAT 080 '012 800 s.Transporter 1 Phone 909-889-5607 2 <br /> 7.Transporter 2 Company Name - - B. US-EPA 1D Number C.State Transporters ID <br /> - <br /> D.Transporter 2 Phone j <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number E.State Facility's ID <br /> Remedy Environmental <br /> 3200 E. Frortera Street F.Facility's Phone ; <br /> Anaheim, CP. 92806 1 CAL 000 200 '500 71:4-630-2 07 <br /> 91.WASTE DESCRIPTION 12- Containers 13. 14. <br /> nit <br /> No. Type Quantity �Tol UNol. <br /> a. <br /> Remedy Environmental Services only acaept� <br /> Non-H4�1US� f <br /> G b docnmeht contained the followin8: <br /> E <br /> N <br /> E <br /> R c. <br /> TDocument#; ,•, <br /> T � �7q) <br /> 3 <br /> T Additionat Descriptions for Materials Listed Above - H.Handling Godes for Wastes Listed Above - <br /> a..) nor:-hazardous water <br /> I <br /> ' PROFILE #04-HMT-01-069 <br /> 15.Special Handling Instructions and Additional information Job Site:. Stockton Facility - <br /> .1990 PiCCOli Rd. <br /> GLOVES & GOGGLES Stockton , CA. .,95215 <br /> - . Er►g. #909--889-5607: <br /> 16•GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment are hilly and accurately described and are in all respects <br /> in proper condition for transport.The materials described on this-manifest are not subject to federal hazardous waste regulations. <br /> Date <br /> printedfTyped Nam Slgnature Month Day Year <br /> e� <br /> r 7 24f <br /> T 11.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> NPdntepTyped Name Signature Month Day Year <br /> P Dale <br /> O 1I-Transporter 2 Acknowledgement of Receipt of Materials <br /> TSignature - Month Day Year <br /> pintedfTyped Name <br /> E <br /> R <br /> 11•Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> J.Facility Owner or Operator;Certification of receipt o1 the waste materials covered by this manifest,except as fln item 19. - - <br /> L Date <br /> Tedrf ii ame Sign Mont DAY <br /> Y -1 • <br />