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Please or type. FormAppmved OMB No.205D-039 UNIFORM HAZARDOdS 1 Generatbr ID Number r 2.Page 1 of a.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C A L 8 2 1 2 0 6 0 4 13 1 = 424-9wo a mw 020060134 JJ K 5� /GROCERY neratoes Name and Mailing AcVress � sl ress[if different than matding address) UPERSTORE INDUSTRIES DIVISION ti'J ,16888 MCIONLEYAVE, Lff HROP CA 96330 Generator's Phone: 2 14 AS 6.Transporter 1 CompaW Name U.S EPA ID Number FREMOUW ENVIRONMENTIL SERVICES INC By. CAR 0 0 0 1 7 1 0 1 7 7,Transporter 2 Company Name U.S.EPA ID Number oeWs�ORLD IlW�IDE RECOVERY SYS5E.M INC CAR 0 0 0 1 7 5 4 2 2 e. U5 ECOLOGY INC U.S.EPA ID Number HWY 9511M 5 OF BEATTY BEATTY NV 89003 Faci!Ws Phoriv 775 553-2203 N V T 3 a 0 0 1 0 0 0 0 ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Num6ff, 10.Containers11.Total 12 Unit 13.Waste Codes HM and Packing Group Cd any)) No. Type Quantity WUN. d1-RQ UN3264,WASTE CORROSIVE LIQUID,ACIDIC,INORGANIC, D002 181 o X N.O.S. (SULFURIC ACID,ABSORBENT) Wt--SS 115 4? :TOOo-1 ' 2 NON-RCRA HAZARDOUS WASTE,LIQUIDS(OILY WATER) 223 I /' 91A 15 3-NON-RCRA HAZARDOUS WASTE,SOLID(OILY DEBRIS, � � 223 ABSORBENT) 4-NON-RCRA HAZARDOUS WASTE SOLID(HOUSEHOLD CLEANERS) 14.Special Handling Instructions anndAdditional Information i)(C)US070137708-12906 -Sulfuric AddlAbsorberft ERM 54 2)US G 070131570-9061 MY terERt#171 3)US G 07128300-8639-Oily Debris E 0171 4)US-G 070128300-30534-Household Cleartlers,Sold CP q )14.� VS--Yl 5 5n �1)I% LA .' {] � L C Fi 4NDI �RB TOSBE 40HR T _,�AMID Li,B p $R 15, GENERATOR'SIOFFEROR'S CERTIFICATION.I hereby declare that the contents of tide consignment are fully and accurately described above by the proper shipping name,and are ch jvfied,packaged, marked and tabeledlplacarded,and are in all respects in proper condition for transport according to applicable IntemaWnal and nalional governmental regulaSons.If export shipment cr am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent I certify that to waste minimization statement Identified in 40 CFR 262.27(a)(111 am a large quantity generator)or(b)(if I am a small quantity generator)is true Cnaragpr sIOA ' s PnintedfTyped Name ature MonthDay Year { �1 �$ V �r ,j16,international iprnents I- ❑Import to U.S. ❑Export from U.S. Port of entryfexit: ?1 Transporter signalure(for Vports only): DfteNaving U.S.: IX 17.TransporWAdunawledgment of Receipt of Materials 11 1� Transporter 1 PrintecYTyped Signature Month Day Ye r R til ti D ti ransporter 2 PrintedlTyped ame Signature /Month pDay Year 18.Discrepancy 18a.Discrepancy indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number I 8b Alternate Facility for Generator) U.S EPA ID Number a V Fac ilitys Phone 4 F1Ec.SignatureDIAltemateFadlityjurGenerator) Month Day Year a z W2 19.Hazardous Waste Report Management Method Codes 5.e..codes for hazardous waste treatment,disposal and recycling systems+ D 1 23 4 22] 20 Designaled Faolity Owner or Operator CerttBcation of" t of azardaus materials covered by the manifest except is noted in Item 18a do yped Name S,naweDay Year (Q�/ 1 EPAForm 8700-22(Rev. 2-1 jrevrOusedi ns Weo6sole —DESIGNATED FACILITYTOGENERATO r