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State of Cakifornia=Environmental Protection Agency 1+ <br /> Form Approved OMB No.2050-0039{Expires 9-30-99f Ses Instructions on back of �• Department of Toxic Sualifor nia ces Control <br /> Please print or,type. form designed for use on elite(12 pitch}ty} <br /> Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 information the shaded areas <br /> UNIFORM HAZARDOUS' is not required by Federal low. <br /> WASTE MANIFEST CAD 9 8 2 5 0 8 2 5 1 4. 8 0 6 5 of <br /> 3. Generator's Name and Mailing Address' ' e , ' <br /> Unified Western Grocers - Attn: Pat GuillermtY <br /> >imen� %,s <br /> h 5200 Sheila Street; COmm-tce, . CA. 90040. . `- <br /> in 4. Generator's Phone f 323 ) 264-5200 <br /> 6. US EPA ID Number toDT�fth r s IrD@1 5 <br /> N 5. Transporter 1 Company Name <br /> &n <br /> g Hoz Mat.Trans Inc. C A T-0 8 0 loll 2 8.0 0 K.. <br /> 7. Transporter 2 Company Name .8. US EPA ID Number <br /> V 4..: <br /> and Site Address 10. US EPA ID Number <br /> 9. Designated Facility Name a - y <br /> _a Crosby & Overton <br /> )Z. 1630 W. 17th Street " <br /> )0 Long Beach, CA. 90813 ICAD 10 12 18141019 0 1. 9 <br /> _� .. 12. Containers 13. Total 14. Unit tsc`'T'r" - x •�_ <br /> Q 1 1. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> Na. T e Quantity WSNoI ,W, <br /> )U <br /> iz <br /> _ 11- <br /> . <br /> F WA <br /> SrE AEROSOLS FLA@MIABLE 2.1 UN1950 <br /> b. <br /> ' . <br /> o f� �4- �y _ <br /> R <br /> o T a 4 s ' <br /> 0 O <br /> w ce <br /> d. <br /> N ,icT1u Aescri 'e3rhAaladl4[s l il '' b4yes 'yia,` ^' jc T� _ <br /> ry <br /> CL <br /> x- <br /> u.e "3-itis' <br /> - �v _, - T �''�"§`; �s,� S �'• S� t'ti.. f t _�,'-�.,' -t:��v�b.�_a, �t`, K p� t <br /> Z 15. Special Handling Instructions and Additional Information <br /> o g jobb Site;Y 1990 Piccoli Rd. <br /> a Stockton, CA. 95205 <br /> Z GLOVES & GOGGLES <br /> L <br /> Emg. ,#909--889-5607 <br /> 16, GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are-fully and accurate)y described above 6y proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition For transport by highway according to applicable international and national government regulations. <br /> If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to-be economicallyy <br /> a Prod'eeable and that Rove selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and Future threat to human hecilth <br /> and the environment;OR,iF I am a small quantity generator,I have made a good Faith effort to minimize my waste generation and select she bast waste management method that is <br /> 'available to me and that I can afford., <br /> 0' <br /> Pri t d/Typed me Signature Month Day Year <br /> Z <br /> T3 7. Trans rier 1 Acknowledgement of Receipt of Materials <br />" R 1 Month Day Year <br /> W A Printed/Typed Nom Signature <br /> R <br /> u.l P <br /> O <br /> 0 1 am <br /> . Frans orter 2 Acknowle en$of Rece! t of Materials <br /> TPrinted/Typed Name S' nature Month Day Year <br /> utg <br /> � R , <br /> V19. Discrepancy Indication Space jA la e,+ 44aZ µ� T 's <br /> ra-h �x ` �'4'S• <br /> Z. -,F 11ti.`C Z Glrww.5 - Na��k;ed eke <br /> C <br /> s <br /> L <br /> f 20- Facility Owner or OperciA Ce 'ficalion Af receipt of hazardous materials covered by thi except as no m 19. <br /> T I.Printed/Typed Name ,�// g Month, Day Year <br /> Y Y Lj;, <br /> DO NOT WRITE BEL W THIS LI <br /> DTSC 8022A 11/94� White: TSDF SENDS THIS COPY TO DT5C WITHIN 30 DAYS, <br /> To: P:O. Sox 3000, Sacramento, CA 95812 <br /> EPA 8700-22 , <br />