Laserfiche WebLink
NDN -HAZARDOUS <br />WASTE MANIFEST <br />6 4. Generator's Name and Malting Address <br />Generator's US EPA ID No. <br />U'li•`ied Grocers <br />1990 Nir"©li Roa6 <br />Qenarator's Phone Stoc"on, CA 95215 <br />S. Transporter Company Name t3. US EPA ID Number <br />Icon Envirorarrera.,,�R Scrvicr,s CAL 000 362,980 <br />B. Designated Facility Name and Site Address 9. US EPA ID Number <br />icon Envirorfinerttaf Services he <br />1.270 `Nhippin Road <br />Q Uniurt Cit1e, CA ,945F7 <br />E <br />N 11, Waste Shipping Name and Description <br />E <br />R a <br />T Non -Hazardous waste, liquid <br />0 �- <br />R b. <br />115. Special Handling Inslnictfone and Addi6onaf Information <br />C -At 000 369 <br />2. Page 1 3. Document Number <br />of <br />N° 10455 <br />i <br />7, Transporter Phone <br />10. Facility's Phone <br />51t�-4TH -?.?rG <br />12_ Conlalners 13. 14, <br />I Py I Sc CC, 1 C'. <br />Handling Codes for Wastes Llated Above <br />11a. <br />16. GENEFIATOR'S CERTtFICAT10N: I certify the materials described above on this manifest are not subject to stale or federal regulations for reporting proper disposal of Hazardous Waste_ <br />Pilniedr yped Name Signature <br />411 <br />A L �/ „ fir Month Day Year <br />N J r <br />SS 17. Transporter Aclmowmedgement of Recelpi of Matsriala <br />HPrinted/Typed Name Signature <br />E- �• Month Day Year <br />R <br />18. Discrepancy Indication Space <br />A SEP 19 2014 <br />c <br />i <br />L ENVIRONMENTAL HEALTH, <br />I <br />T DEPA.RTN4EN <br />Y 19. Facility Ownef or operator. Certification of receipt of waste materials covered by this manifest except as noted in Item 18. <br />PrinkOfTyped Namo Signature <br />Month Day Year <br />WHITE —ORIGINAL (peturrl to Generator) YELLOW —TSOF (Retain Copy) PINK —TRANSPORTER COPY GOLDENROD —GENERATOR'S COPY <br />