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r NOS, HAZARDOUS WASTE.MANIr _ST <br /> Please print gr type (Form designed for use an elite(12 pitch)typewriter) Manifest <br /> - <br /> NON-HAZARDOUS 1.Generators US EPA IDNc. Document <br /> 2.Page 1 <br /> DoeumentNo. 53881 of 1 <br /> ` WASTE MANIFEST mp 982 5Q8 25 <br /> 3.Generators Name and Mailing Address - <br /> Unified Western Grocers-Attn:, Pat Guillermety <br /> 5200 Sheila Street, Cbrumrce, CA. 90040 <br /> 4.Generators Phone( 323 )264-5200 <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.State Transporters ID <br /> Haz Mat , CAT 680 012 80Q B.Transporter 1 Phone 909-889-5607 Transporter 2 Company Name 8. US EPA ID Number C.State Transporters ID _ <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10.: US EPA ID Number E.State Facility's ID <br /> Remedy Envirnonmental <br /> 2000 E Brundage Lane- F.Facility's Phone <br /> Bakersfield CA.' 93307 CAL 000 220 398 - <br /> 1852 <br /> 14. <br /> 11.WASTE DESCRIPTION 12.- Containers 13. <br /> Total Unit <br /> No. Type Quantity Wtivol. <br /> NON-HAZARDOUS WASTE LI U D / T T G <br /> G b. <br /> E <br /> N REN"Y EWIRONMENTAL SERVICES Only . <br /> E ezclnded recyclable <br /> R c. material.Water or ERN[shipped on this dornment <br /> A contained the following: <br /> T Total Units: <br /> R d• <br /> W <br /> 71^C:;=.11C 3t or Manifest 4. <br /> Cl) <br /> 4H.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above - <br /> N a. ) non-hazardous water <br /> 0 PROFILE #04--H -01-069 <br /> a <br /> Q15.Special Handling Instructions and Additional Information Job Site: Stockton Facility. <br /> _ 19.90 Piccoli Rd. <br /> Z GLOVES & GOGGLES Stockton, CA. 95215 <br /> Z Emg. #909-889-5607 <br /> 18.GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment are fully and accurately described and are in all respects . <br /> in proper condition for transport.The materials described on tt7ia manifest are not subject to federal hazardous waste regulations. <br /> Date <br /> PflnrYTyped Name SignatureMonth Day Year <br /> Q e� <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R <br /> Ip Pr'n a yped Name Sign Month Day Year <br /> O18.Transporter 2 Acknowledgement of Receipt of Materials. pate <br /> TPrintedrryped Name Signature Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space ' <br /> L <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 /> 1 Printedlryped Name Signature, Month Day Year . <br /> Y �e�s a eek �- o <br /> F-1402002 L.AaEAA5M6(81H7)821-5W8 www.lat l.aster-corn mPP1WTpr+gECYdEpPAPER Rev.3195 <br /> �'+ ��.,..enwc.0 icer ee.v ruv <br />