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NON-HAZARDOUS WASTE MANIFEST <br /> Please print or typo . (Form designed for use on elite(12.pitch)typewriter) - <br /> NON-HAZARDOUS 1.Generators US EPA ID NDocument No. <br /> o. Manifest P.Page 1 <br /> WASTE MANIFEST CAD 982 508 251 of <br /> 3.Generators Name and Mailing Address. c . <br /> Unified Western Grocers - Attn: Pat Guillermety ' <br /> 5200 Sheila Street, Ctomerce, CA. 90046 <br /> 4.Generators Phone( 323 264-5200- <br /> 5,Transporter 1 Company Name- 6. US EPA ID Number - A.State Transpoftees.ID - <br /> Haz that Trans In sooB.Transporter.)Phone _ <br /> 7,Transporter 2 Company Name - 8. US EPA 14 Number G.State TransWrtars ID - <br /> fl.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address "19. US EPA ID Number - E.State Facility's ID - <br /> Remedy Environmental <br /> 2000 E. Brundage Lane F.Facility's Phone <br /> 1 i2. Containers 13: 14. <br /> 1.WASTE DESCRIPTION <br /> Total Unit <br /> 'No. Type Quantity Wt.Nol;��f <br /> NON-HAZARDOUS WASTE LIQUIDS �/`-'�/ <br /> G b. .. - <br /> Remedy En�irof► ntal ervices 1y accepts <br /> NNon-Hnzs�d�.:, ,� ter. <br /> F 4,-r ��;1r don this <br /> R doc:umern contaid c the oltowing <br /> A = <br /> Ttotal Units: q& i <br /> IR d. <br /> Document <br /> • .G.Additional Descriptions for Materials Listed Above - H.Handling Codes Ior Wastes Listed Above . <br /> a. ) non-hazardous water . <br /> PROFILE #04-HMT-01-069 . <br /> 15.Special Handling Instructions and Additional Information ,lob Site:., Stockton Facility:,. - <br /> 1990 Piccoli Rd. <br /> GLOVES & GOGGLES' Stockton, CA. ..95215 <br /> #903-889=5607 <br /> Ni.GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment are fully and accurately described and are:in all respects <br /> in proper condition for transport.The matenals described.on this manifest are not subject to federal hazardous waste regulations- <br /> Date <br /> PrintedrFyped N c' Signature" ,Month Day Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials - r 'Date <br /> R <br /> A Prin y d Name Sign r <br /> IN <br /> f Year <br /> IN <br /> P 18.Transporter 2 Acknowl ement of Receipt of Materials ' <br /> p Date <br /> T PrintedrTyped Name Signature Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> ! 20.Facility Owner or Operator;Certification of receipt of the waste materials covered by this manilest,except as noted in item 19. <br /> L Dale <br /> Td Name S groat }fonts Day . Year <br /> YOao Gr?. <br /> r <br />