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f <br /> r P w'r'iter. <br /> Reese print or type.(Form designed for use on elite(12-pitch)type ) Form Approved.ONIB No,2050-0039�,Manifest Tracking Number <br /> t.Generator iQ Number 2.Page 1 of 3.Emergency Response P, I 9 <br /> UNIFORM HAZARDOUS _,; ,;, l ,13.a )4-5-oo� G B F <br /> WASTE MANIFEST C AJ_.--8_._08 25 - +. <br /> 5.Generator's Name and Mailing Address Generators Sita Address[.'tf different than mailing address) <br /> Lrdfied Western Grocers Unified Wester Crrocdrs <br /> 5250 Sheila Street Commerce Via. 90040 1900 Piecoli Road:P.0 Box 60753 <br /> I_T <br /> i X23 t 264-5200X200 m mal-Aji x,StocktoM Ca. 9 5215i 90660 <br /> Generators Phone: U.S.EPA ID Number <br /> 6.Transporter 1 Company Name <br /> San Joaquin Filter ltecyclin CAI 0[NJ102751 <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> B.Designated Facilitymetd Si Addre s U.S.EPA ID Number <br /> cr er I ac3 Iii' <br /> 1423 ' E. N.'annmi g. Parlier, CA. 93648 <br /> 554) 4918-02-10 CAL000102751 <br /> 2751 <br /> Facility's Phone: <br /> 9a. <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11.Total 12.Unit 13.Waste Code HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> '21 <br /> N ON RCRA Hazardous Waste, <br /> o Liquid(Usad Oil,"'Niixed Oil) � Ti <br /> LU 2- <br /> u.r — <br /> c <br /> i <br /> 3. <br /> i <br /> 14.Special Handling Instructions and Additional Information <br /> v. ;1?i 9F 1 17 €'rotiif X9131: {.:used O:M- fixed tail "Appropriate Personal Protective <br /> Equipment <br /> 15. GENERATOR'SIOFFEROR'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, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the t®mxs of the attached EPAAcknowledgment of Consent. <br /> I certify that the wiste minimization statement identified in 40 CFR 262.27{a)(if I am a large quantity generator)or(b)(ii l aM a small,quantity generator)is true. <br /> torslOffe fs P yntedrfyped Name <br /> ture tiM1onth pay Year <br /> 1 emation.l Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit: — <br /> Z .Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Month Day Year <br /> Trans ort er 1 Printed/Typed Name Sign <br /> Monih Day Year <br /> d Transporter 2 PrintedlTyped <br /> Name Signature <br /> t- <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type t�J Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18¢.Altemate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> u. Fachity's Phone: Month Day Year <br /> C) 18c.Signature of Atter <br /> rate Facility(or Generator) <br /> a .. <br /> Z <br /> 19.Hazardous Waste Re ort Management Method Codes(i.e.,codas for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. <br /> 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a <br /> PrinMK <br /> %..-kName <br /> Si a Month Day Year <br /> c-+L �` \-- C". r� 1' - Z-- 10,.. <br /> FPA Form 8700-22(Rev.3-05) Previous editions are obsolete. ___.__._--- —._.. —I-- wrur-.�^r3 <br />