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L NOI.�iAZARDOUS WASTE MANIk GST <br /> Please print of type , (Form designed for use on elite(12 pitch)typewriter) - <br /> NON-HAZARDOUS 1.Generator's US EPA ID No. Manifest 2.Page t <br /> Document <br /> WASTE MANIFEST CAD 982 508 251 °f <br /> 3.Generafo?s Name and Mailing Address <br /> Unified Western Grocers - Nttn: Pat Guillerinety <br /> 5200 Sheila Street, Commerce, C.N. 90'040 ­ <br /> 4.Generator's Phone( 323) 264-5200 - <br /> 5.Transporter 1 Company Name 6. US EPA 1D Number A.State Transporters ID - <br /> Haz Mat Trans, Inc. CXT 080' 012 800 S.Transporter 1 Phone — <br /> 7.Transporter 2 Company Name B. US EPA 10 Number C.State Transporter's ID <br /> D.Transporter 2 Phone <br />'I 9.Designated Facility Name and Site Address - 10. US EPA ID Number E.State Facility's ID <br /> Remedy Environmental p � ��'aa-r <br /> t Ln�.�/��"tG� ��2 �s.8 F.Facility's Phone <br /> CAL 714-630-2307 <br /> jeffl,11.WASTE DESCRIPTION 12. Containers 13. 14, <br /> Total Unit <br /> No. Type Quantity WtJVW. <br /> I <br /> a. <br /> I C7 <br /> NOv-3�ZARDOUS 'TASTE LIIUIDS <br /> I <br /> G b. <br /> E REMEDY ENVIRONMENTAL SERVICES Only <br /> E :accepts Non-hazardous water/excluded itnecyclahle <br /> t Water or shipped on this document_ <br /> II a' contained the following: <br /> T Total Units: <br /> W R d• 1',_ :rmet or Manifest li: IF3 6 <br /> aG.Additional Descriptions tot Materiais.Listed Above H.Handling Codes tot Wastes Listed Above <br /> N a. ) non-hazardous water <br /> n <br /> PROFILE #04-HMT�01-019 <br /> a <br /> a15.Special Handling Instructions and Additional Information Job Site: S tockton.' Facility . <br /> 1990 Piccoli Rd. <br /> Z GLOVES & GOGGLES- S-tockton, CA;: 95215 <br /> O <br /> Z €I E, 909-889-5607 <br /> 16.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 this manifest are not subject to federal hazardous waste regulations. <br /> I I. <br /> Data <br />{i PdntedlTyped Nam ,�.. Signat C Month Day Year <br /> 5A, J aZ IZ7107 <br /> T 17.Transporter i Acknowledgement of Receipt of Materials - Date <br /> R It <br /> A Prin d Name Signa rZa <br /> Month z7 <br /> S Day Year <br /> " � � <br /> P ,�i <br /> ie.Transporter 2 Acknowledge en1 of Receipt of Materials . <br /> Date <br /> T Printed/Typed Name Signature Month Day Year <br /> i R <br /> 19.Discrepancy Indication Space - - - - - - - <br />�I C 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 /> l <br /> TPrintedlTyped Name T Signature Month Day Year <br />{I Y Z C3 <br /> F-1402002 LAULOW TFR®(Boo)621-swe www.Wmnlaster.com PRINIEDON RECYCLED PAPER ne wn. Rev.3195 <br /> 0 USING SOYBEAN INK <br />