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NON -HAZARDOUS <br />WASTE MANIFEST <br />r 4. 0enan tor'a Nemo entl Mailing Addroae <br />1. GenaratoN US EPA ID No_ <br />Unified Grocens <br />1990 piccoli Road <br />Stockton, CA 95225 <br />Generator' Phone <br />5, Transporter Company Name 6. US EPA ID Number <br />ICCs Fpusror), ;Mtal Ser vires CAL 000 352 980 <br />S. Designated Faelliiy Name and Sete Addresa 10. Ug EPA ID Number - <br />Icon Enviroomental Sen(, -es Inr, <br />1220 Whipple React <br />L°:iiort City, CA 94587 <br />r 11. Waste Shipping Name and Description <br />N <br />E <br />R a. <br />T Non -Hazardous Waste, liquid <br />0 <br />R b. <br />I 1 15. Special Handling Instructions and Additional Information <br />CAL 000 369 026 <br />2. Page 1 3. Document Number <br />of 1 No 10540 <br />7. Transporter Phone <br />10. Faality'a Phone <br />510;-476-1740 <br />12. Ctritalners I 13. <br />Handling Codas for <br />11e. <br />Clean Tech Envivenmer►tal <br />16. GENERATOR'$ CERTIFICATION: I certify the materials deserlhed above on this manifest are not subject to stale or federal regulations for <br />A <br />Prinlad/Typad Name <br />Kilo <br />Signat1ur}It <br />N <br />17. Transporter Aeknowle meet of Receipt of Materials <br />P <br />O <br />PrintedflWad Name <br />Signature <br />E <br />18. Diacrepancy Indlcatlon Space <br />Listed Above <br />disposal of Hazardous Waste, <br />Month Dey Yaar <br />Month Day yasr <br />A SEP 19 2014 <br />c <br />j <br />L ENVIRONMENTAL HEALTH <br />T DEPARTMENT <br />Y 19. Facility Owner or Operator; Certillcation of receipt of waste materials Covered by thla manitaat except as noted in Item 16. <br />Printed/Typod Namo I Signature <br />Wnth Day Year <br />WHITE —ORIGINAL (Return to Generator) YELLOW —TSDF (ROAln Copy) PINK —TRANSPORTER COPY OOLDENROD —GENERATOR'S COPY <br />