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V111W I.r Please print or type.(Form designed for use on elite(1 2-pitch)typewriter.) Form Approved.OMB Na.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Ma ifest Tracking Number v WASTE MANIFEST C A D 9 8 2 5 0 8 2 5 1 1 909-889-5607 0 0 0252916 JJ K 5.Generator's Name and Malting Address Generator's Site Address(if different than mailing address) Unified Western Grocers U.W.G. Attn:Fat Guillermety,5200 Sheila Street 1990 Piccoli Rd. Commerce CA 90040 Stockton CA 95215 Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number Haz Mat Trans, Inc. C A T 0 8 0 0 1 2 8 0 0 7.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 8 4 0 9 0 1 9 ga @b.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 wt.1vol. rr 1. U N 1960,WASTE Aerosols, FLAMMABLE D001 331 2.1 DM 7J P z 2. C 3. 4 14.Special Handling Instructions and Additional Information 9b. 1) aerosols - Profile # 51192 Gloves & t=oggles 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, marked and fabeledlplacarded,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 conform 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) it I am a small quantity generator)is true. Generator's11j- ! rots PrirtedA), Name Signature Month Day Year J 16.International Shipments t— ❑Import to U.S, ❑Export from U.S. Port of entrylexit Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials XJ Transporter 1 Pdntedrry Name Signature Month Day Year c 0 ran= der 2 Printedrryped Name Signatur Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity L1 Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: I 8b.Alternate Facitty(or Generator) U.S.EPA 10 Number U CC Faclitys Phone: W 18c.Signature ofAitemate Facility(or Generator) Month Day Year Q Z 19.Hazardous waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) UJ 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a PrintedlTypedName Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)