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NW *.r <br /> Please print or type.(Farm designed for use on elite(12-pitch)typeWniter.) Form Approved.(3M6 No.2050-0039 <br /> UN <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUSFt1ASTE MANIFEST C A p g 8 2 5 909-$$9-5607 1 000252917 J J K <br /> 5.Generators Name and Mailing Address Generator's Site Address(lt different than matting address) <br /> Unified Western Grocers U.W.G. <br /> Attn: Pat Guillermiety,5200 Sheila Street 1990 Piccoli Rd. <br /> Commerce CA 90040 Stockton CA 95215 <br /> Generator's Phone: <br /> 6.Transporter 1 Company arU.S.EPA 0 Number <br /> e <br /> GAT 0 8 0 0 1 2 8 0 0 <br /> Haz Mat Trans Inc. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.designated Faollty Name and Site Address U.S.EPA ID Number <br /> Siemens Water Technologies Corp. <br /> 5375 South Boyle Ave. <br /> Vernon CA 90058 <br /> FaciAys Phone: cog 266 ;W47- <br /> 9a 9b.U.S.DOT Description iinduding Proper Shipping Name,Hazard Class,ID Number, 1o.Containers Ciu Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(If any}) No. Type Quantity Wt.Nol. <br /> rx1 Non-RCRA, Hazardous Waste Soiid 559 <br /> 0 (oillabsorbent) DM P <br /> z 2. <br /> LU <br /> CD <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and AddUnal information <br /> 9b. 1) diesel/oil/dirt/absorbent - Profile # AP168384 <br /> Gloves & Goggles /,Q 6z9-3 <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 natlonai governmental regulations.If export shipment and I am the Primary <br /> Exporter,l certify that the contents of this consignment conform to the teras of the attached EPAAcknowledgment of Consent. <br /> I car*that the waste minimization statement idenfifled in 40 CFR 262.27ia)(if I am a large quantity generator)or(b)('rf I am a small quantity generator)is true. <br /> Signator Month Day Year <br /> Generator' Offerofs Print Eryped Name ply <br /> C) e <br /> —J 18.International Shipments ❑Import to U.S. Export from U.S. Port of entrylexit: <br /> Z <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LLJ 17.Transporter acknowledgment of Receio of Materials <br /> Transporter t Print yped Name <br /> Signature ManLh Day Year <br /> d l rL,��q <br /> DoDay Year <br /> Zo rine rier 2 P htkfryped Name Signator th <br /> Q <br /> H <br /> 18.Discrepancy ��}} <br /> 18a.Discrepancy Indication Space ,Quantity Ely,. ❑Residue Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> rat Facility's Phone: Month Day Year <br /> pyj 18c.Signature of Alternate Facility(or Generator) <br /> a <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � Z7 <br /> 1. � 2. 3 4 <br /> I20.Designated Facility Owner or Operator:Certification of recWt of hazardous rials covered by the manifest except as noleyIn ItA 180, <br /> F I — 1"') <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-65) Previous editions are obsolete. DESIGNA ED FACII_iTY TO nFl;iINATION STATE(IF REQUIRED) <br />