Laserfiche WebLink
- <br /> NON-HAZARDOUS 1.Generator ID Number 12.Page 1 of 3.Emergency Response Pham 4.Waste Trecking Number <br /> WASTE MANIFEST <br /> S.Generator s Name and Mailing Address Generators Site Address(if different than mailing address) <br /> unified Western Grocers-Atte: Pat Guillermety Stockton Facility <br /> 5200 Sheila Street 1990 Piccoli Rd, . <br /> CA. 90040 Stockton, CA. 95215 <br /> U.S.EPA ID Number <br /> 6.Transporter 1 Company Name <br /> CAT 080 012 800 <br /> Z Mat Trans, Inc U.S.EPA ID Number <br /> 7.Transporter 2 Company Name - <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Remedy Environmental <br /> 2000 E. Brundage Lane CAL 000 220 398 <br /> ggsfield, C.A. 93307 (661 ) 637-1852 <br /> Facil ha <br /> No Type Quantity W1Nol. <br /> 9a. 9b.U.S.DCT Description(including Proper Shipping Name,Hazard Class,ID Number, o.Containers tf.Total i2.Unit <br /> HM and Packing Group(ii any)) <br /> 1. <br /> cc <br /> a� INON-HAZARDOUS WASTE LIQUID J T T G <br /> w _ <br /> 1. <br /> 3. <br /> 13. Special HandlingInstructions Additional Information <br /> 9b.1 ) non-hazardous waste _. Gloves & Goggles <br /> Profile #07--iimr-10-0409 - <br /> Appointment #07994 <br /> 14.GENERATOR'S CERTIFICATION:i certify the me.tertals described above on this manNest are not SuNerLto federal regulations for reporting proper disposal of Hazardous Waste. <br /> Sig fore `` Month Day Year <br /> Geners ofelOfferors Print dnyped Name S <br /> A 15.International Shipments ElImpart to U.S. ❑F�kport from U.S. Port ai emrylexkb V is <br /> Trarworber Signature ior exports an : Date ieavin U.S.: : <br /> 16.Transporter Acknowledgment of Receipt of Mafertale Month Day Year <br /> Tr nor 1 PrintsdlTyped Name Slgnstu/4p6 if <br /> _.... <br /> r <br /> A r Month Day Year <br /> Transporter 2 PrintadTyped Name <br /> 17.Discrepancy <br /> i7a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial ReJeotlon ❑Full Rejection <br /> Manifest Reference Number. <br /> U.S.EPA ID'Number <br /> 17b.Atemate Facility(or Generator) <br /> Facility's Phone: Month Day Year <br /> w 17c.Signature of Alternate Facility(or Generator) <br /> N is aN"� a`C 7 rP"'41y� s' • a rt+i <r a rt. 4 E ✓ t j ..£ a t tf':A.. , ` ' <br /> �fi� ;�i .{/y`&, a�i� ,� � %+i {��,� �' � g+ e f a' '� $ ,M�lg!I,lt`.k1 E y,, �•= e", d._':€ ."' '1'9i Y`� '- ` @t <br /> 18.Designated Facility Owner or rator.Certification of receipt of hazardous matsnats covered by the manifest except as noted in Item 17a Month 21 —Yeed Name Signature t <br /> DESIGNATED FACILITY TO GENERATOR <br /> iF4.R1 r-O 5 10498 -_ <br />