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NG. _ :HAZARDQUS.WASTE MANS. . <br /> Please print or type (Form designed for use on elite(12 pitch)typewriter) <br /> 1.Generator's US EPA ID No. Manifest 2-Page 1 <br /> NON-HAZARDOUS EXEMPT ;Document No. 53174 of 1 <br /> WASTE MANIFEST. ` <br /> 3.Generators Name and Mailing Address <br /> Unified- Western Grocers '-'.Attn:. Pat Guillermety <br /> 5200 Sheila ,Street, , Commerce, CA: 9UU40 <br /> Ih <br /> 4.Generator's Phone( 323 ) 264-5200 - - - <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.State Transporters ID <br /> Haz Mat Trans, -Inc. CAT. U80 012 800 .. B.Transporter 1 Picone 909-899-5601 <br /> 7.Transporter 2 Company Name 8: US EPA ID Number C.State Transporter's 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 Environmental.. .. <br /> 3200 •E.. Frontera Street F.FacilitysPhone <br /> Anaheim, CA. 92806 'CAL OW200 5OU ' 714-630-2307 <br /> ii.WASTE DESCRIPTION - 12. Containers 13. . 14. <br /> Total Unit <br /> No. Type Quantity WLNOL <br /> a " I <br /> NOX-HAZARDOUS WASTE LIQUIDS <br /> E b. <br /> N REI.ftV F'r"j` iiiAL <br /> ' - -Amen � F!5 3rP/CSCIIIdCd CL�C�1 - ' <br /> R c. natc6t!$1 Way-, _: : *-.ir Mable <br /> Al oolra li�l�0: ,r.,, 'ryf?'d en.fhis.dtlmrrtWt <br /> f T <br /> f o <br /> d <br /> W or Man;cest.#; <br /> .74I G..Additlonal Descriptions for Materials Listed Above " H.Handling Codes for Wastes Listed Above <br /> N a.) non-hazardous water -- <br /> D <br /> C PROFILE #04-HMT—U1—U69 k <br /> i N 15.Special Handling Instructions and Additional Information, 'Joh �-Si.te• Stockton -Facility <br /> 1990•=Piccoli Rd. <br /> Z GLOVES &.GOGGLES Stockton, CA: ":.95215 <br /> 0 <br /> Z Ein 909-889-5607 <br /> AWMMMMAW <br /> I p <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 /> . Date <br /> I Prince Name Signatu Monts Day Year <br /> tr1 eta <br /> 19/103PZ <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> A Pr�iede r/ y Slgnatur r Month Day Year <br /> P Z/11�.!)/ r-5 107 <br /> ' . <br /> p 18,Transporter 2 AanowfFdgement of Receipt of Materials Date r <br /> TPrinted/Typed Name. Signature Month Day Year <br /> E <br /> I R " <br /> 19.Discrepancy Indication Space - - - <br /> A 65 <br /> i <br /> 1 20.Facility Owner or Operator,.Cortification of receipt of the waste materials covered by this manifest,except as:noted in item 19. <br /> L- . <br /> k I Date <br /> T zl <br /> dlTyped oma Sign ( Mon Day Year = <br /> Y r ' a r� e � D d <br /> I' F14 L MMLAASM'*(800)621-6W8 www.k"rnaster— - pwrw oN REcYmo PAPERrn�no rmx Rev.3/95 <br /> USNO SOYBEAN INK SrYV IMK <br />