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Cf <br />NON HAZARDOUS WASTk MANIFEST <br />UNIFIED GROCERS <br />1990 PICCOLI ROAD <br />STOCKTON CA <br />CITY, STATE <br />209-931-1990 <br />PHONE <br />EPA NUMBER: <br />LIST COMPONENTS: <br />A. DIRT <br />B. WATER <br />C. n1 <br />D. <br />PHYSICAL STATE. <br />WASTE DESCRIPTION: <br />DIRTY WATER <br />GENERATING PROCESSCLARIFIER WATER <br />SPECIAL INFORMATION:P-ED-H <br />THE GENERATOR CERTIFIES THAT <br />THE WASTE AS DESCRIBED IS 100% X <br />NON -HAZARDOUS. <br />71665-1 <br />MANIFEST NUMBER <br />LC 2 z... R -') <br />ZIP / / DATE <br />T /� <br />QUANTITY <br />E. <br />F. n <br />G. n <br />H. In <br />❑ Liquid <br />❑ Solid <br />SEP 19 2014 <br />ENVIRONMENTAL HEALTH <br />DCPARTIVIE:I <br />TRUCK # <br />PIU DATE: "2 <br />rc717S SNC <br />P.O. Box 5129 San Bernardino, CA 92417 19091889-5607 D VE N I <br />f; D.O.H.S. #0115 ■ EPA #CAT 080012800 <br />X �-C�- <br />:'°�''I SPECIAL HANDLING <br />-PURE WATERWORKS <br />OR DISPOSAL METHOD <br />9A' � <br />NAME fDATE <br />J 910 ROCHESTER AVENUE <br />({' ADDRESS <br />ANCHO CUCAMONGA CA 91730 <br />i CITY, STATE ZIP <br />_949PH. <br />'y PHONE <br />EPA NUMBER. - <br />Au O AG .NT <br />QUANTITY <br />