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r R. <br /> NOIR AZARDOUS WASTE MANN 'T <br /> Please print or type (Form designed for use on elite(12 pitch)typewriter) <br /> NON-HAZARDOUS 1 Generator's US EPR ID No. Document No. 2 Page 1 <br /> WASTE MANIFEST CAD 982 508 251 48280 of <br /> 3.Generator's Name and Mailing Address - - <br /> Unified Western Grocers Attri: 'Pat Guillermety <br /> 5200 Sheila Street, Commerce, .CA. 90040 <br /> 4.Generators Phone( iii <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.State Transporters ID i <br /> Haz Mat Tran Inc. s:Transporter 1 Phone — <br /> 7.Transporter 2 Company.Name 6. . US EPA ID Number C.State Transporters tD <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address - 10. US EPA ID Number E.State Facilitys ID f <br /> t <br /> Remedy Environmental <br /> 3200 'E. Frontera Str tLaDLQim CA 928 CAT, 000- kn 500 F.Facility's Phone <br /> 714-A-10-21 <br /> 11.WASTE DESCRIPTION 12. Containers i3. 14. <br /> Tota! �/yG Unit i <br /> No. Type Cluantit (JV W1Nol. <br /> -E LiFiculag' <br /> NGN—T4A7.aEEUj,; WAST <br /> E b. .Remedy Environmental Services only accepts <br /> N Nan-Hazardous :eater. Water shipped on this <br /> E <br /> R c. <br /> A <br /> Total Units: <br /> d' <br /> W Document#: Lj <br /> G.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above <br /> p a.) -non-hazardous water <br /> O PROFILE #04-HMr-01-069 <br /> a - <br /> 15.Special Handling Instructions and Additional Inforehatibn Job Site: Stockton Facility <br /> _ 1990 Piccoli Rd. <br /> GLOVES & GOGGLES . Stockton, CA. 95215 <br /> i <br /> 16.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,materials described on this manifest are not subject to federal hazardous waste regulations. <br /> Date <br /> Print7hTyped Name, - Signator Month Day Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials - - Date <br /> pPrinted/Typed Name - Signature Month Day Year <br /> P I <br /> 0 16.Transporter 2 Acknowledgement of Receipt of Materials. Date <br /> R Printeeyped Name Signature Month Day year <br /> T <br /> E <br /> R ' <br /> 19.Discrepancy Indication Space <br /> A ' <br /> C <br /> 20,Facility Owner or Operator,Certification of receipt of the waste materials covered by this manifest,except as noted in item 19. l <br /> L Date <br /> '�' rint ,yped Nam Si T' Mora Day Veer } <br /> Y �^ <br /> k7,,e,6� 6 '1 A&L <br /> F-1402002 :'LMlELAASTFA S(0)0}$21-NW WWW.I84BImSr'I%•COm POMO oX RECYCLED PIPER Rev.3195 'J <br /> i usmsoy"M {NK i <br />