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wore or l.altorma—tnvironmenlol Protection Agency Form Approved OMB No.2050-0039{Expires 9-30-99) t � See Instructions an back OFYp4 �1. Department of Toxic Substances Control Please prim or type. form designed for use on elite(12-pitch)f ^41i� Sacramento,California inerator's US EPA ID No. _ Manifest Document I. - 2. Page 1 information in the shaded areas r UNIFORM HAZARDOUS is not required by Federal low. WASTE MANIFEST ,-1 S? 1) '3 � 7 1 . 0 02 5 of 1 3, Generator's Name and Mailing Address #�� A. State Manifest Document NumberAttn: Pat Gurr�� ' Unified Western Grocers G .&S . Q 5200 Sheila Strut B..State Generator's ID . LO t1ftllt rs �A 0 x s[ 4. Generator s P ono '� 4-5200 ti • - �s;- '. ii N 5. Transporter I Company Name 6- US EPA'1D Number C. State Tronsporter's Il] Reserved-]:' ' - - D. Transporter's Phone '- �`uy - 0 Haz Mat Trans Inc. �E� m 7. Transpo.ter 2 Company Name 8. US EPA ID Number .E.'State Trans orter`s,lD' eserveJ_J '' ' 'J :Trcnsporters•Phone,^-," ;tU 9. Designated Facility Name and Site Address 10, US EPA ID Number G."Slate Facilitl/s,�FD 3yY. la U-S. Filter R n+eily Sete ces f�alirrgia), Inc.Irra. f H.�Facah s'Phone .% "�, rx vxk £ 4 5375 South Boyle Ave. .� 1ietTlOs1 CA 90058 12. Containers 13. Total 14..Unit. ,::€;` "_ :~%,a'ss:'•n- Q 11. US DOT Description(including Proper Skipping Name,Hazard Class,and ID Number) F lU P 9 P PP 9 No. Tye Quantity VJt/Vol '!:`Waste Number; •:- Z a. 5#die:.` '• >., :,..,�.-,,. .,•. Nan-RCRA, Hazardous Waste Solid :-: 35 2 ~ :EPA/0th 3 G 'NONE`, oN b' Non-RCRA, Hazardous Waste Liquid state 2.9.1 EPA/Oth a ML3iE. ,r c- State 6 CD d ' EPA/016r I R LU d. State i U EPA/_,Qthw ul 2 1. Additional Descriptions for Materials Listed Above - K. Handling Codes for Wastes Listed Above o �L tailtdirt/grease/absorlaent-Profile c- a. b. `. #P16W7 L! L latex paintfwater-Pm ile#(Also: . a 3431 Q15. Special Handling Instructions and Additional Information I GlOvcas & Goggles Job Site: 1990 PiCcoli Rte. Z Stocktora, CA. u, Emg. 4969-889-5607 x .:j 16. GENERATOR'S CERTIFICATION- I hereby declare that the contents of[his consignment are fully'and accurately described above by proper slopping name and are classified,packed, Umarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. J -� If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically �- practicable and ihol I have selected the practicable method, treatment;storage,or dispbsol currently available to me which minimizes the present and future threat to human health V) and the environment;OR,if I am a small quantiy generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is W available to me and that I can afford. 1 O ).. Prinled/Typed .---.,.t Signature--:. ' a ""� Month /Day Year T 17. Transporter I Acknowledgement of Receipt of Materials C9 R S Pri Typed Si e Month pay Year [/�� ILLj LL 0 18• Transporter 2 Acknowledgement of Receipt of Materials _ T Printed/Typed Name1-s4oture Month Day Year Lei f ' i en R V19. Discrepancy Indication Space Z F A C I L I f 20. Facility Owner or O erator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19, � T Printed/Typed Nome Signature - Month Day -Year� l r Y I r .DO NOT WRITE BELOW THIS LINE. } L DTSC 8022A f1/991 Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. ] EPA 8700-22 To: P.O. Box 400, Sacramento, CA 95812-0400 i I �