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New <br /> Form Approved.OMB No.2050-0039 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.)- 2 page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS 1.Generator ID Number - - <br /> WASTE MANIFEST C A D S 8 1 5 Q f1 .,'. �> 1 1 qw 869'`J6t?r 003214614 JJ K <br /> Generator's Site Address(N different than mailing address) <br /> 5.Generator's Name and Mailing Address <br /> JrTifte,7 Western Grocers u W G. <br /> ATtn'.Peat Gemomety. 6200"AwAlo S1TP:49t i59U F tcroa{ort, <br /> [:.mwnerce I-A W A 1 <br /> Cercerator's Phone: ; 'I ; ^ it ijT' <br /> U.S.EPA 10 Number <br /> S.Transporter 1 Company Name <br /> Haz taut Trans, Int, <br /> U.S.EPA ID Number <br /> 7.Transportar 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> Cre"tk u%w1lon <br /> 1630v'4 17th 8t6et <br /> LON Bemrh CA !90813 C R IJ D 2 8 A g 9 l! 1 9 <br /> Facilitys Phone: F -N6dAr <br /> OT Dription(including Pyr Shipping Name,Hazard Class,ID Number, 10.Containers Type Quantity <br /> Total 12.antity WWI. <br /> Unit <br /> 9a. 9b.U.S.Descol. 13.Waste Codes <br /> HM and Peaking Group(if any)) No. <br /> rc IUN19W. Wa3teAercr de- ) Q(lUi 343 324 <br /> z 2 <br /> w <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOWSIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper Shipping name,ard are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenl of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if 1 am a large quantity generator)or(b)(AI am a small quantity generator)is hue. <br /> Genemtors/Offeror's PdntedRyped Name Signature - Month Day Year <br /> k.. tr 7 <br /> 16.International hipmenls <br /> C' ❑Import to U.S. ❑Export from U.S. Port of enhylexiC <br /> = Transporter signature(fa exports only): Date leaving U.S.: <br /> K 17.Transporter Acknowledgment of Receipt of Materials <br /> w Month Day Year <br /> � 7rensporter I PdnteNryped Name Signature j <br /> d ::r- , . , <br /> t P ,<, Day <br /> rn Month Oay Year <br /> QTrensporter 2 Pnnledrryped Name Signature ' <br /> K <br /> t18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑TYpe ❑Residue ❑Partal Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 181d.Mtemale Facility(or Generator) U.S.EPA ID Number <br /> J <br /> LL Facility's Phore: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> a <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,atm recycling systems) <br /> G L t 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:CeNBration of receipt of hazardous materials covered by the manifest except as niched in Item IBe <br /> illl Pdnted/ryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />