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N,.. AZARDOUS WASTE MAN T <br /> Please print or type (Form designed for use on elite(12 pitch)typewriter) .- 2.Pae 1 <br /> NON-HAZARDOUS 1.Generators us EPA ID No. .; Manifest g <br /> Document Na. �����— of T . <br /> WASTE MANIFEST I C)D 9.12 503 251 <br /> 3.Generators Name and Mailing Address " - - <br /> Jnifie I Western Grocers—k"n: <br /> 5240 Sabila Street, aa),tw rc', 96349 . <br /> 4.Gerierators Phone( 323} 254-5230 <br /> S.Transporter 1 Company Name 6. US EPA ID Number A.State Transporters ID <br /> JdZ lci` ']C3Y15, tnC: Cw 080 112 300 B.Transporter 1Phone <br /> 7.Transporter 2 Company Name <br /> g, US EPA ID Number C.State Transporters SD " <br /> - D.Transporter 2 Phone <br /> 9.Designated Facifty Name and Site Address S0. - US EPA ID Number - E.'Sfafe Facility's ID <br /> 2440 E. <br /> Brm-layer Line F.Facility's Phone <br /> Ba' rsfi t✓l , C.I. 93317 C)- L'090; 220 398 551.—637 .1352 <br /> 12. Containers 13. 14. ::,,` <br /> 11.WASTE DESCRIPTION Total Unit <br /> No. Type Quantity WQVol. <br /> a i�r <br /> G b <br /> E <br /> N <br /> E <br /> R c- <br /> A <br /> T <br /> .. O <br /> Rd. <br /> W <br /> H - . <br /> Q G.Additiona4 Descriptions for Msateria8 Listed Above H.Handling Codes for Wastes Listed Above <br /> a.) water <br /> N <br /> I' '407-:-Iasi'-10--3409 <br /> i N 15.Special Handling Instructions and Additional Information .Job Sits: Itocitt-W '151acili ty <br /> Q r+'-Y+�+t• - <br /> 1,990 "icw i R.I. _ <br /> r Z L7, a;[El,' GOCI ,Mt1r. ES I St.clot nffl CN.-95215 <br /> Z Eaj "909--839-3607, <br /> 16.GENERATOR'S CERTIFICATION:I hereby certify that the contents o1 this shipment are fully and accurately described and are in all respects <br /> in proper condition for transport.The materials described on this manifest are not subject to federal hazardous'waste regulations. <br /> Date`e - <br /> PrintedlTyped Nam Signature Month Day Year <br /> i e 7� 2 <br /> T 17-Transporter 1 Acknowledgement of Receipt of Materials ! Date <br /> Fi Month Da Year <br /> A Pnnt ed Name Sign r y " <br /> V3 107 <br /> P 18.Transporter 2 Acknowledgement of Receipt of Materials Date <br /> PrintedlTyped Name Signatiire: Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space - - <br /> F <br />{ C <br /> 20.Facility Owner or Operator,Certification of receipt of the waste materials covered by this manifest,except as noted in item 19. <br /> ` L Date <br /> T Printed(Typed Name Signature Month Day -."Year <br /> i Y. <br /> F-1402002 LQWLAAYM6(1700)821-5848 www.labelmaster.aom �PRniTE)oNRECrCLEDPAKII RiM,rowi, Rev.3195 <br />