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4+ Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number ((�� pp WASTE MANIFfsT C , 1 ", .r •t O 0'0 3 4 6 J?5 G R F 5.Generator's Name and Mailing Address Generator ate `d rens(if Different than mailing address) Ulntified-Western Grocers Unified Westeni grocers 5200 Sheila Street Connnerce Ca. 90040 1900Pict;oli Road'P.0 Brix 60753 Generator's Phone: -� _ 6.Transporter 1 Company ame EP,41 tJhmber � .J. 7.Transporter 2 Company ame a U.S.EPA I u 6rOO ' B.Designated Facility Name and Site Address U.S.EPA ID Number Facilit es Phone: + i iii 1 499-0240 ga_ 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity WtNol. 1. Liquid (Used 0it Mixed Oil) 3 T, / G 2. W 3. 4. 14.Special Handling Instructions and Additional Information N AERG0 9B I 171* Profile V%31: t-'s>rcf C iL°;vlixccl Oil *AppropriO: Personal Protective Equipment 15, GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeiedlplacarded,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 Exporter,I certify that the contents'of this consignment c:onfarm to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true GeneratVsrO a Pri rteoff Signatur= Month D Year UAI -J 16.International Shipments ❑Import to U.S. ❑Export fror[rU:S. Po entrylexit: z Transporter signature(for exports only): Date leaving U.S.: Oe 17.TransporterAckno wledgment of Receiptof Materials Month Da Year Transporter 1 Printecirryped Name`` Signature y p / �s a ed Name - + Signature Month. Day Year W Transporter 2 PrintedrTyp �+ H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity EJType ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number 18b.Altemate Facility(or Generator) U.S.EPA ID Number Facility's Phone: LU 18c.Signature of AliFacility(or Generator) Month Day Year Q z 19.Hazardous Waste Repast Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) UJ 0 1 H141 2 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pdnled[Ty Namg Signature Month Day Year 1:��14 (�er-k� -I EPA Form 8700-22(Rev.3-05) Previous editions are obsolete.