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Stole of California—Environmental Protection Agency See tnstructio on back of p�Jb• Department of Toxic Substances Control <br /> Form Apprc qd OMB No.2050-0039(Expires 9-30-99) t4l.4 Sacramento,California <br /> Please print":'.type. Form designed for use on elite(12-pitch) '_rifer. 2 1 Information in the shaded areas <br /> 1. ,eneraSor's US EPA ID No. Manif-sl Document No.- Pageis not required by Federal law. <br /> UNIFORM HAZARDOUS of <br /> WASTE MANIFEST C I A I D].9 18 12.5 101812 1 <br /> A Biose Manrfesi Document Number^ � i +� <br /> 3. Generator's Name and Mailing Address �, " -"3 h t �' <br /> Attn: Pat Guillerme <y� ,,- `' <br /> Unified Western Grocers B{Stare Generator,s 641 <br /> 5200 Sheila Street <br /> A 99040kn <br /> w� <br /> C''StateYTrarispartes h lD[Reserved] § ^z# � �- � <br /> an <br /> p Company Name <br /> .6. US EPA ID Number <br /> C. 5. Transporter I Com _ <br /> ys ^t <br /> m D Tra sporteF'a,F one-,", <br /> 0 Inc <br /> c0 8. US EPA 1D Number E'5tate$FransQorter6slD Reserved r s rr A; <br /> } 7. Transporter 2 Company Name - <br /> a <br /> a � <br /> 10. 'US EPA iD Number G <StatesFauhty `+_ti�ja� ~j �„ rs <br /> Designoted Facility Name and Site Address ? S ,��t,k;- 'i� ` i '3". <br /> Crosby 8s Overton <br /> `z <br /> #a 1630 W. 17th StreetAn 0 <br /> ; ' <br /> Jng Beach CA 90013 12. Containers 13. Total <br /> 11. US DOT Description(inc4uding Proper Shipping Nome,Hazard Class,and IQ Num6arl No. T pe Quantity', WI/Vol %C°:'1Nasfe{Number ;. <br /> t <br /> 5tote <br /> WASTE Aerosols Flammablep EPA/.0t r <br /> 2.1, UN1950 ;. l� L} '! t <br /> N r <br /> R WASTE PAINT, 3, UN1263, P.G. II D M G YEPA/others r <br /> 1. Eml <br /> fV - STate <br /> rr A cis z ,i <br /> O T <br /> ao O <br /> LU d, <br /> ZLLj <br /> EPA/Other a a"� zs.; <br /> i La T f r K.,Handbn Codes For Wastes Listed Above c F i <br /> I ]'�Addrtronal Descripirons for Materials Listed Above 1 f 4 h_ ;.�. Z g ., 3'� t r Y+T �'r, - '' <br /> a x <br /> 8 a. (I}aerosol -flarrlmabie 'Profile c r SeF tis <br /> #151:192 ERG#126 r 4 <br /> r t <br /> LU <br /> x � d . <br /> j b: waste palet 'Profile# d:, <br /> E- Q 15.-Special Handling Instructions and Ac6tional Information 11A- <br />[ Q Gloves & Goggles Job .Site: 1990 Piccoli Rd. `! <br /> I Z Stockton, Cid. 95215 �/* /.I�� <br /> I 2 Emg. #909-889-5607 <br /> r <br /> JJ 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of,this consignment are fully and accurate( described above by proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in oil respects in proper condition for transport by highway according to applicable interriational and national in regulations. <br /> l 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 economical{y <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal Currently available to me which minimizes the present and future threat to human health <br /> and the environment;OR,if 1 am a small quantity generator,I have made a good faith effort to minimixe:my waste genaration and select Ike best waste management method Ihof is <br /> available to me and that I can afford. <br /> Op.' ped Name Sign use Month Day Year. <br /> Z <br /> rs.t T 17. Trons orter 1 Ack6owled ement of Receipt of Materials <br /> LU M Print d/Typed N e Signature Month Day Year <br /> Ll S <br /> p1 B. Trans orter 2 Acknowled emeni of Receipt of Materials <br /> T Printed/Ty ed Name Si at Month Day Year <br /> 0 <br /> LU <br /> U F 19. Discrepancy Indication Space - <br /> Z A r <br /> C <br /> I <br /> 1 20. Facili Owner or O erator Certific n of race of hazardousmaterials covered b rs m ifem exce t as nosed in Item l9. <br /> . T Printed/Typed Name Q `Year <br /> Signature Month- <br /> Y (nf <br /> DO' NOT WRITE ELO T LINE_. <br /> f - <br /> i <br /> Whiie: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> DTSC 8022A (1/99) To: P.O. Box 3000, Sacramento, CA- 95812 <br /> EPA 8700-22 <br />