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Please Print or h.e Form Approved OfAB% 20510.01039 <br /> UNIFORM HAZARDOUS I Generator 1D Number 2 Page 1 of 3 Emergei,ry Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST r, 020183694 FL E <br /> 5 Gere ado"!;Na^re ain mari ng Address Generator's SI �dress(if Merem than mailing address) <br /> SUPER Kf',G `-OOD CENTER MAILING SUPER KING FOOD CENTER <br /> X26 N. LOWER SACRAMENTO ROAD STE. 20 1449 W. MARCH LANE <br /> STOCKTON, CA 95210 STOCKTON CA 95207 <br /> Gene•al&s P'+o,ie{92 5)20 1-9511 <br /> 6 Transporter 1 Company Name US EPA ID Number <br /> Atl's Er-m-onmerltal Solutions AR000295220 <br /> �Company Name <br /> Y W I� V U , �� �� U S EPA ID Number <br /> F De w-are;Fac-q Name and Ste Address NEPA ID Number <br /> Ve-)lia ES Technical Solutions LLC <br /> 1704 W First St CAD048302903 <br /> Azusa, CA 91702 <br /> l'ac I,Ys Phone 62T5-&14-5117 <br /> Ra 9b U 5 DOT Desrnption(including Proper Shipping Name.Hazard Class,ID Number, 10 Containers_ 11 Total 12 Unit 13 Waste Codes <br /> Elm and Packing Group If aril No Type Quantity WI rVol <br /> ON-^903, Waste Pesticides, liquid, toxic, flammable, n.cl 331 !JO36 <br /> X [flash point not less than 23 degrees q , 6.1 (3), II ` DF IC3 P ---- <br /> LJ w <br /> M 2 <br /> LU <br /> c.7 <br /> 00c <br /> �,,e a a c rc ^s.' �sandAddlGonallnformaLonul-nent: D415401 <br /> ERG#131 <br /> GENERATOR SCFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and adeurately described above by 1ha proper shipping name,and are classified,packaged <br /> marked and labeled pia:aided.and are in all respects in proper condition for transport according to applicable international and national governmental regulations If export shipment and l am the Primary <br /> Exporter.I cerkfy that the contents of this consgnment conform to the terms of the attached EPAAcknowledgment of Consent <br /> I i that the waste minimization statement identifed in 40 CFR 262 27(a)fd I am a large quantity generator)or(b)(d I am a small quantity generator)is true <br /> GeneratorsIO.fferdrs Pnnted.Typed Name Signature Month Day Yea• <br /> L ICft SIS <br /> �; Z <br /> AI <br /> 'S Intematonal Shipments <br /> r ❑Import to U S ❑Export from U 5 Port of entry7exd <br /> z Transporter signature(for exports only) Date leaving U S <br /> '7 Transporter A lkwMedgrnl of Receipt of Matenals <br /> w <br /> —ars x ner inled Typed Name Signature Month Day Year <br /> v ZS <br /> e' ,ic' SIn <br /> hlpn,n Day Year <br /> X <br /> r <br /> 18 D 5crepancy <br /> 5a D svepancy Ind,eal Space El <br /> Quantity Type LJ Residue ❑Partial Refection ❑Full Refection <br /> Manifest Reference Number <br /> r Alternate Fa:rility for Generaor QQP&`Ie�- US EPA ID Number <br /> \\-W�A Y"L <br /> 0 <br /> wh.lerlh Day yr.0 <br /> 4 ' <br /> Z g ` <br /> 19 Haiaro;,us fvosle kk:W4 t Irlena5emenl I&AF1 d J, r- r,cde5 for hazardous waste t(ealment,disposal,and recycling systems) <br /> LU <br /> LU 1 r 3 a <br /> 0 <br /> 20 Desgnateci Facility Owner pr Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item id i <br /> >nn!r,Typed Nwne Sgrature Manlh Day <br /> EPA Form 8700.221Rev 12.17) Previovseditions are obsolete DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />