COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Please print or type.F(Form deslgned far use on elite(12 pits t typewriter.) Form Approvrsd.OMB No12050-6039 UNIFORM kAZARDOUS 1.Generator ID Number 2.Page i of 3.Emergency Response Phone 4.Manifest Tracking Number {� -I�[ WASTE MANIFEST1. V 0 O.2 5 0 O 9� j�+,K. 5.Generator's Name and Mailing Address Generators SiteAddress(if different than mailing address)' (AftW westem Grocers U.W.G. Attn:Pat GUik T)*.5200 Sirs b Street 1990 Picts Rd. Ct�rce CA 901M , Saari On 'CA 96216, . Genera o s one: 6.Transporter 1 Compan N e " - U.S.EPA ID Number .x Haz at U:S.EPA ID Number:; _ 7,Transporter 2 Company Name ----- 8.Designated Facility Name and Site Address U.S.-EPA ID Number C(y10�5�b��Y•&1710p 1630 W. h S 8eeth1 CA 9W1 : ' Fa'it s ne: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 1f}.Contain_ess :11,Total 12.Unit 13.Waste Codes.:. HM' and Packing Group(if any))' .. Nd. Type Quantity Wt VOI." WASTE Aerosds : X 2.t,UN1950Du Vb UJI , Ell 2 - 1 R SUSSBqM OFMS - 3' I, JSAL.1XIE'. .LENT Ok RE1;SE(TtpSBV,A OVENTON INC'WMA r'Fs HE FA UNDF - �.F•+[tl'S(;kAYlF1�I-L`r1IiM.B :IS ns pF3'ARTktL'1-r OF TOXIC StrtiSr NCE L'ONTR4 TOOERff '. ,-� 111E F14VIRONMENTAL PKCII MION AG r'Y,IN ACCORDANCE Tr}r'111f PR0 1SIDN5 - . «iii.'k1SUURCE C•'JNS13(VAnON ANG }LF.CUt-F t AVI OF 1976, i - 4 .. c.`.. L AND STATE: REGULATIONS.-CRUs.BY R:Os'E3t'I'ON HAS 1:4F -nm ;'FRNITTS TO ACCEPT SNE XBRERENL'EDWASTE AND ALL TTS,WA FiAS B TiANIMi�.r 14 Special Handling Inshdons and Add itona Information :, ' , ,X -75 :1)' aerosols ff'laiftTTtable} Profile #51192 Gloves ar Gog�lss f5, GENERATOW810FFEROR'S CERTIFICATION: I hereby dedafe that the contents of this consignment are fully and aocurately described above by the proper shipping name,and are dassified,packaged'�_ ) marked and labeled/placarded,and are in all respects in proper condition for bansport according to applicable international andnationat governmental regulations.if export sNpment and I am the Primary Exporter,l�itifythat the contents of this consignment confomi to the terms of the attached EPAAcknowledgment of Consent: I certity,that the waste minimization statement Identified in 40! U CFR 262.27(a)(if I am a large quantity generator)or(b)(if(am a small quantity generator)is true '. Gene slDtferors P' lType6.Name-, -Signa ted Month Da� Year ; ILI r 16.Intemational Shipments 3 :i ❑Import to U.S. f ❑Export from U S' -,.Port of ehtrylexit: Transpvrie'signature(for exports only}: ;-t. - Date leaving U.S,: W 17.TransporterAcW,6wledgmsnt of Receipt of Materials Tran porter 1 PH ted/Typed Name Signature Month Dayr Year O Z U . z Transporter 2 Printecayped Name: igna n Day' ,Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type , ❑Residue ❑Partial Retecbvn ❑Full Rejecbon Manifest Reference Number., 18b.Alienate Facility(vr Generator} U.5 EPA ID Number Facillys Phone: Month Day.- Year W i8c.Signature of Altemate Facility(or Generator) N19,Hazardous Waste Report Management Method Codes(i.9.,codes for hazardous waste treatment,disposal and recycling systems) - A 20.Designated Facility Owner or Operat Certifi receipt ofhazardous materials covered by t as rroted in Item 18a �- PriiltedlTyped Name Signaiu r Doth �D Year EPA Form 8700-22(Rev.3-05) Prev editions are. ete. DESIGNATED.FACILITY,TC GENERATOR.