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," Iwo Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.20500039 UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C A D 9 8 2 5 0 8 2 5 1 1 909-889-5697 0 Q 0 2 5 2 9 1 7 JJ K 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Unified Western Grocers U,W.G. Attn: Pat Guillermety,5200 Sheila Street 1999 Piccoll Rd. Commerce CA 90040 Stockton CA 95215 Generator's Phone: 6.Transporter 1 C mpany erne t U.S.EPA ID Number Haz Mat Trans, Inc. GAT 0 8 0 0 1 2 8 0 0 U.S.EPA Ip Number 7.Transporter 2 Company Name B.Designated Facility Name and Site Address U.S.EPA ID Number Siemens Walter Technologies Corp. 5375 South Boyle Ave. Vernon CA 90058 Facile s Phone: ga 9b.U.S.DOT Description(incuding 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.Nol. 1. Nor}-RCRA,Hazardous Waste Solid (oil/absorbent) DM P z 2. c� 3. 4, 14.Special Handling Instructions and Addltionai Information 9b. 1.) diesel/coil/dirt/absorbent= Profile # AP168384 '-X� Gloves & Goggles 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 dessified,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,I 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 262.27(x)(if I am a large quantity generator)or(b)("rf I am a small quantity generator)is true. Generator' Oiferors Print fTyped Name 9ignatu Month Day Year Im a ell� ' -J 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Port of entrylexit: K Transporter signature(for exports only): Date leaving U.S.: IX 17.Transporter A_i n wlcdgment of Receipt of Materials LLJ Transporter 1 Printed ypetl Name Signature Month Day Year rens rter 2 P ntedfryped Name Signaler oath Day Year tY F- 18.Discrepancy 181 Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Altemate Facility(or Generator) U.S.EPA ID Number J_ C7 cC LL Fadiity's Phone. w 18c.Signature ofAltemalle Facility(or Generator) Month Day Year Q Z Fn19.Hazardous Waste Report Management Method Codes(i.e.,codes far hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Hem 18a PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-45) Prev€ous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)