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PC,:,,). Department of Toxic Substances Control Stale of California—Environmental Pretedion Agency See Instructions On back Of P Sacramento,Colilcrnia Form Approved OMB No.2050-009!(Expires 9.30-99) Please print or type. Form designed for use on eYte(I 2-pitch)t)' `ter. Manifest Document No. 2. Page 1 Infarmatian in the shaded areas 1. ,ererator's 05 EPA ID No. is not required 6y Federol law, UNIFORM HAZARDOUS rJ rj of 1 WASTE MANIFEST (; A $ 2 5 $ i A. State ManiFest Document Number 3. Generator's Name and Mailing Address Attn: Pat Gulllerm 24.771669 Unified Western Grocers B, State Generator's ID 5200 n s ala�A et a. .ne,JI or Ar one 3.N026-'4-r,--)nn C. State Transporter'5 1D[Reserved.] I� 6. US EPA ID Number _ - cV 5. Transporter 1 Company Name - D. Transporter's Phone' 90'' 889_5607 I O HaZ Mat Frans Inc. 8. US EPA ID Number E. State Transporier's ID[Reserved.( T 7. Transporter 2 Company Name - LF. Transporter's Phone ' J G. State Facility,ID Number K. i0. US EPA ID 9. Designated Facility Name and Site Address - U.S. Filter Recovery Services(California), Inc. H. Faciliy's.Phone 0 5375 South Boyle Ave. 323:' 277-. ffl0. ra. _ 12. Containers 13. Total 14. Unit - Q No. Type Quantity Wt/Vol I. Waste Number,, 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) yp Slate - z a. Nan-RCRA, Hazardous Waste Solid EPA/otl;e' fIVONE: 3 G Slate. ' E . b N 6. - :EPA/Other. - m E p R State = IC4A O T EPA/011ier m 0 R State E Z EPA/Other Its iu K. Handhn :Cedes For Wostes Listed Above j U J. Additional•DescrpliansFor'MateriblsListed .4bova - = _ 6-•' - a. O a oflfrlirf/greaselabsortyent-Profile " P'165407 w z 15. Special Handling Instructions and Additional Informotion Job Site; 199 © Pi cco li Ra . Gloves & Goggles Stockton, CA. 95215 - i z LW Emg. #909889-5607 H 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of.this consignment are fully and accurately described 6bavIt by proper shipping tame and are classified,packed, Q marked,and labeled,and are in all respects in proper condition for transport 6y highway according to oppli,; 6le international and national government regulations.. 1 If I am a large quantity generator,I certify that"I hove a proggram in place to reduce the volume and toxicity of waste generated to the degree 1 have determined to to economically a- practicable and that S have selected the practicable method of treatment,storage;or disposal currently available to me which minimizes the present and future threat to Kumon health and the environment;OR,if 1 am o small quantily generator,I have Made a good faith effort to minimize my waste generation and select She best waste management method that"is ` O available to me and that I can afford. Month Pay Year If UPrinted/Tye Name Signature r Z r orae s 'w T 17. Trans rter 1 Acknowledgement of Recei t of Materials R Month Day Year A Printed/Typed Name Signature I a [f � R :Z Q /� 4:5y U- r! 18. Trans orter 2 Acknowled ement of Recei t of Materials Month Day Year 0 R Printed/Typed Name Si aSure N T F R (aj 19. Discrepancy Indication Space F Z — A f 4, f 20. Facili Owner at O erator C lift attar of rete! t of h a u at rials covered b this manifest exce't as d in Item 19. Month Day Year T Printed/Typed Namet Signature y DO NOT WRITE BELOW THIS LINE. While: TSDF SENDS THIS COPY TO OTSC WITHIN 30 DAYS. Box 3000, Sacramento, CA 95812 DTSC 8022A{1/99( To: P.O. EPA 8706-22