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" De cirtrrent of Toxic Substances Control <br /> (tate of California—Environmental Protection Agency ,r: See Instructions on back of page p Sacramento,California <br /> :orm Approved OMB No.2050-0039(Expires 9-30-99)(I2 ;1ch N' ,vril T y, <br /> 'lease print or type. Form designed for use on elite f 12'P" ) 2- Pae 1 "Information in the shaded areas <br /> ,herator's US EPA•ID No, Manifest Document i g is not required 6y Federal law. <br /> (UNIFORM HAZARDOUS 0_r- `� .. 1 5 of � <br /> WASTE MANIFEST •1!i `"# => ' G} <br /> f ��A. State Manifest Document Number . 's 6 9- <br /> 3. Generator's Name and Mailing Address - A Pat Sa3.ftlieFT"Sf77116 <br /> i nd'ied Westerri Grocers, B. State Generator's 1D , <br /> 5200 Sheila Street <br /> A. Generator's Phone I 32 ) 2I3 wrr200 <br /> D Number <br /> C. State Tronsporter.'s ID(Reserved-1 <br /> 6. U5 EPA I <br /> V5. Transporter 1 CompanyiNariie - <br /> o D. Transporters Phone; <br /> j <br /> HaZ Mat TCclSSSS 1nC- 8. E. State Transporter's ID IReaerved.l <br /> US EPA ID Number <br /> D 7. Transporter 2 Company Name -- <br /> Fr'Ttahspcirfersislioae•F <br /> 1 <br /> G. stale Facility's IV- <br /> 9, <br /> Q <br />' Q - T 0. US EPA 1D Number <br /> '1 9. Designated Facility Nome and Site Address ,a+ " <br />- q 1j-5, FSlt$fReCLVe"Y r40B5(California), ino- H.eFaclitjr's-Phone2771 <br /> 5375 South Boyle Ave. 3 � '' . ,•" <br /> 0 Vemon CA 90058 12. Containers 13. Total 14. Unit: <br /> Wt1Vol 'k.`,VJo3te:Nam6er;' <br /> Q i 1. US DOT Description{including Proper Shipping Name,Hazard Class,and ID Number) No• Type" Quantity Stale <br /> i%.. �.. .j_ .. <br /> Z Non-RCRA. Hata-ldous�i rgte lie: � :� EPAIOth' <br /> 3 G state <br /> E <br /> p N b• EPA_ <br /> /Other <br /> m E <br /> < R state <br /> (N A c <br /> O T EPA/O <br /> Ther <br /> opo O <br /> R `State <br />! d. EPA/Other <br /> Z <br /> E V <br /> L" <br /> 1 °"K. Handling Codes for Wastes listed Above <br /> V) J. Additional Descriptions For Materials Listed Above <br /> Vve <br /> 6 <br /> Z ail cliff r stn rbent- Pf0file <br /> a; d. <br /> Tt, d. <br /> a ` <br /> Z 45. Special Handling Instructions and Additionallnformotion kcal] Etc? <br /> GIOV05 A C�gglas Job Sit i <br /> a <br /> 3t-ockton, CA.L <br /> ETtzt3 !3 5c�t)": <br /> f ~ <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above 6y proper shipping name and are classified,packed, <br /> l <br /> Q marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> t If I am a large quantify 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 <br /> i practicable and that t have selected the practicable method of treatment starager or.disposal currently available to me which.minimizes the present and future threat to human health <br /> and the environment;OR,if I am a small quantity generator,I have made a:good faith effori to minimize my waste generation and select the best wasie management method that is <br /> W available to me and that I can afford. <br /> O Signature � 1'1 Month Ray �+Year <br /> �. Printed/Ty Name ,. � sp'S'r;� 1,,.� <br /> Zj J C/4�SJ r"1 <br /> w T 17. Trans orter 1 Acknowled ement of Receipt of Materials Month Day Year <br /> R <br /> Signature <br /> A Printed/Typed ame J s <br />{ cit P <br /> J_ a 18. Trans orter 2 Ackhowleclement of Receipt of Materials Month Day Year <br /> Q R Printed/Typed Name s' nature <br /> T <br /> LU E <br /> x' - <br /> i Q R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> C ---------------; <br /> f <br /> 20. FacilityOwner or O erator Certification of recei t of hazardous materials covered b this manifest except as noted in Item 19. Month Day Year <br /> I� T Printed/Typed Nome signature <br /> Y <br /> DO"NOT WRITE BELOW THIS LINE. <br />{ Biue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> DTSC 8022A(1/991 To: P.O. Box A00, Sacramento, CA 95812-0400 <br /> EPA 8700-22 <br />