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Asa-PhA IJ i 1—C6 <br />WHITE -ORIGINAL (Return to Gertarotor) YELLOW -TSDF (Retain Copy) PINK -TRANSPORTER COPY GOLDENROD -GENERATOR'S COPY <br />NON -HAZARDOUS <br />1. Generator's Ids EPA ID No. <br />2. Pegs 1 <br />3. Document Numbor <br />WASTE MANIFEST <br />N° 1 7 <br />4. Generator's Name and Mailing address <br />l gni; IPr� Groeers <br />1990 Piccali Road) <br />ST.,xktonr. CA 95215 <br />Generetoea Phone <br />5- Tranaporter Company Name 0. US EPA ID Number <br />7. Transporter Prone <br />Icon Environmental cervices CAL 000 362 980 <br />& Deaignatad Facility Name and Site Address 9. US EPA ID Number <br />10. f=acility's Phone <br />k4ifi Ertvironmental Services Inc <br />510-75-1740 <br />1.220 Whipple € oad CAL 000 359 925 <br />I.Jinion City, CA 94587 <br />G <br />N11, <br />Waste Shhipping Name and Description <br />12. Containers <br />t13t01 <br />14. <br />E <br />No. <br />_CLtR0Ny <br />W001 <br />A <br />a Non -Hazardous ase,liquidCrr; <br />N-Hrdwt <br />_I f <br />-1. <br />�;U� <br />T1 <br />vim. <br />,..`� <br />0 <br />R <br />b. <br />15. Special Handling Instructions and Additional Infamlatlon 7:, <br />-Handling Codes for Wastes Listed Above <br />Ila. N b. <br />Y: <br />a <br />SEP 19 2014 <br />CIPan. TKh Environrnpntil <br />ENVIRONMENTAL HEALTH <br />19.OENERATOR'S CERTIFICATION. I certly the materials described above on this manifest are not subject Io,Pals Or fpdlRal <br />rcqulalions for reporting proper disposal of Hazardous waste. <br />Priraeed/Tjrped-�Iame� <br />�) <br />Signature i f f% <br />T <br />R <br />J /--v pJ J' <br />/ <br />Month Day Year <br />N <br />S <br />17. Transporter Ad owfodgement of Receipt of Matsdals <br />0 <br />O <br />Ptintedrfyped Name <br />t <br />f ; <br />18. Discrepancy Indication Spans <br />F <br />A <br />C <br />L <br />T <br />Y <br />1 a. Facility Owner or Operator. Carttfication of recelpt of wasta materials Covered by alis manifest Lx2Mt as noted in Item 18, <br />Printsd/Typed Name <br />Sipnaturo k <br />/ <br />Month Day Ybar <br />WHITE -ORIGINAL (Return to Gertarotor) YELLOW -TSDF (Retain Copy) PINK -TRANSPORTER COPY GOLDENROD -GENERATOR'S COPY <br />