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NON-HAZARDOUS 1,Generator ID Number 12.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST CAD 982 508 251 1 909-889--5607 55180-A <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Unified Western Grocers Stodkton Facility <br /> 5200 Sheila Street 1990 Piccoli Road <br /> Cormyvarde, CA 90040 (323) '264-5200 Stockton, CA 95215 <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number . <br /> Baz 'Mat Trans, - Inc. CAT 080 012. 800 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> E <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Remedy Environmental <br /> 2000 E. Brundage Lane <br /> Faoil sfield, ' CA .93307 (661.) ' 637-1852 CAL 000 220 398 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Paddng Group(it any)) No. Type Quantity WtNol. <br /> Non-Hazardous Waste Liquids TT / ,,� G <br /> 2. <br /> w . <br /> cs - <br /> 3. m. <br /> 4. <br /> 13. Special Handling Instructions and Additional information <br /> 9b.1 ) non-hazardous water Gloves & Goggles <br /> Profile #07-HMT-10-0409 <br /> 14.GENERATOR'S CERTIFICATION:I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. <br /> Generator slOHeroesZdaWypad Name Signa Month ©a1� Year <br /> Aj <br /> J <br /> 1 15.International Shipments <br /> Impart.to U.S. ❑Export tram U.S. Port of enirylexft, <br /> Transporter Signature ffore rts only): Dat le U.S.: <br /> cc 16.Transporter Acknowledgment of Receipt of Materials. <br /> Transpo 1 'nt ype�N @ /f ` Sign r Month Day, Year <br /> CL <br /> /,(y'!/ilk/ ��LJ, C,�`_.- <br /> ZTransporter Printsd7yped N Signature Month Day Y <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Qum <br /> ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number. <br /> 17b.Ahemaie Facility(or Generator) U.S.EPA ID Number <br /> V <br /> rat Facirr y's Phone: <br /> 17c.Signature of Ahemate Facility(or Generator) Month Day Year <br /> a <br /> :^��Dom§ �SQi�..p.�;°,•- :�..<� '� �a s `� ' '�,. `� <br /> 18.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 17a <br /> Printed/Typed Name Signature Month Da Year <br /> 169-BLC-0 6'10498 DESIGNATED FACILITY TO GENERATOR <br />