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Please print a�type.(Form designed for use on elite 02-pitch)1ypewriter.) Form Approved:dMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2,Page Tof 3.Emergency Response Phone 4.Ntanifest Tracking Humber WASTE MANIFEST CAD 9 $ 2 5 Q $ 2 5 1 1 909-889-58Q7 0 0 0 250096- J J K Generators Site Address(if different than mailing address) 5.Generators Name and Mailing Address Unified Western Grocers U.W.G. Aftn: Pat Guillermety,5200 Sheila Street 1990 Piccoli Rd. Commerce CA 90M Stockton CA 95215 Generators Phone: 1 9 1 9 6 - U.S.EPA ID Number 6.Transporter 1 Company Name Haz.Ma#Trans, Inc. � C A T 0 8 0 4 1 2 8 0 0 U.S.EPA 10 Number 7.Transporter 2 Company Name 8.Designated Facility Name and SileAddress U.S.EPA ID Number Siemens Water Technologies Corp. 5375 Sot,rih Boyle Ave. Vernon CA 90058 C A D 0 9 7 0 3 0 9 9 3. FacitiSys Phone: gM 210-7747 ' 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes 9a' No. Type Quantity WiNot. HM and Packing Group ff any)) 1'Non-RCRA,Hazardous Waste Solid . 352 DM. P 3. _ 4. 14,Special Handling Instructions and Additional Information 9b.1) absorbent/oil/diesel/antifreeze- Profile .#AP168384' Gloves & Goggles fX 15. GENERATOR'SIOFFEROWS CERTIFICATION,i hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper conditlon for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowtedgmeni of Consent, generator)is true. I certify that the waste minimization statement identified in 40 CFR 262.27(x)(41 am a large quantity generator}a(b)(ifl am a small quantity g " Signatur Month Day Year Generator'61 rot's Print yped Name Q 16.International Shipments ❑Import to U.S. ❑Export from U.S.- Port of entrylexit: �- Date leaving U.S.: Z Transporter signature(for exports only): 17.Transporter Acknowledgment of Receipt of Materials Month Day Year Transporter 1 PrinladlTyped Name Signature �^ tan1 Signa Month Day Year za Transporter 2 Printed)Typed Name a r 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑TYPe ❑Residue 0 Partial Rejection ❑Full Re}action . ❑ Manifest Reference Number: U.S.EPA 10 Number 18b.Attemate Facility(or Generator) V W Faaliy'sPhone: Month Day Year w 18c.Signature of Alternate Facility(or Generator) " z V519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal;and recycling systems) LU 1. =2. 3. 4. 20.Designated Fadi Owner 6r Opera or:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a Month Day Year. PriniedlTypedlfamer}/�///�� Signature � ` EPA Form 8700-22(Rev.M5) Previous editions are obsolete. DESIGNATED FAc TY T DESTINATION STATE(I.F REQUIRED)