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Phrase print or type.(Form designed for use on elite(12-pitch)typewriter.) Farm Approved.OMB No.2050-0039 3.Generator ID Number 2,Pae 1 of 3.Emergency Res orse Phone 4.Manifest TrackingNumber UNIFORM HAZARDOUS g 9 Y P 000252916 JJ K WASTE MANIFEST C g D g g � � 0 $ 2 5 1 1 90'x$$5-5607 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Unified Western.Grocers U.W.G. Attn: Pat Guillen-nety, 5200 Sheila Street 1990 Piccoli Rd. Commerce CA 90040 Stockton CA 95215 Generator's Phone: _ 6.Transporter 1 Company Name U.S.EPA 0 Number Haz Mat Trans, Inc. C A T 0 8 0 0 1 2 8 0 0 Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Crosby 8 Overton 1630 W. 17th Street Long Beach CA 90813 Facility's Phone: C A D 0 2 4 0 9 0 1 9 9a. 9b.U.S.D07 Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit ny)} 13.Waste Codes HM and Packing Group(if a No. Type Quantity Wt.Nel, 0 1 UN 1950,WASTE Aerosols, FLAMMABLE D001 331 2.1 i `rd DIM J P w z 2. u� C7 3 4. 14.Special Handling Instructions and Additional Information 9b. 1) aerosols - Profile # 51192 `J Gloves & Goggles 15. OENERATOR'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 labeled/placarded,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, certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 282.27(a)(if I am a large quant6ty generator)or(b) n I am a small quantity generator)is true. Generators! ff ror's PnniedlT ed Name Signature Month Day Year J 15.International Shipments F- ®Import to U.S. ❑Export fram U.S. Port of entrylexit: Transporter signature(for exports only): Date leaving U.S.: IX- 17.Transporter Acknowledgment of Receipt of Materals a Transporter 1 Pririted,`TV Name Signature Morth Day Year 0.0) L�� d�A� IV)-f- o7ransp&e1r 2 PrintedfTyped Name Signalu Month Day Year rY H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J C) LL FarlitysPhone: C3 18c,Signature of Alternate Facility(or Generator) Month Day Year Q Z v519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) O 1. ` 2. 3. 4. f Li - 1 20.Designated Facility Owner or OperatorSNcahlt of hazardous materials covered by -nlfest exce tem 18a Printed/Typed Name Signa e Month Day Ye A ( ��--� EPA Form 8700.22(Rev.3.05) Previou ons are obso 't D tGNATED FACILITJ TO DESTINATION STATE (IF EQUIRED)