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DepartmeM of Toxic Substances Control <br /> k of.­40�. California <br /> kad ji---*ee ns ructicins on bac <br /> 'ornio—Environrnentcil projection Agency Sacramento, <br /> -d 0,M11 No.2050-0039(Expires 9-30-991 <br /> Form designed for use on elite(I 2-pikh' % Page 1 tion in the Shaded areas <br /> 1.Generator's Manifest Document No� Information <br /> not required by Federal low. <br /> UNIFORM HAZARDII��1111111 I! of <br /> WASTE MANIFEST A D <br /> N ar <br /> A:�SiPi* J� <br /> 3. Generator's No Aft,' Pat Guillerm <br /> Unified Western Grocers <br /> t <br /> Q', <br /> ID <br /> ;StateGene[U or s. <br /> 52M Sheila streat <br /> to <br /> to 4.CrqMMVrFRn ;�15 =4-5�ZCIQ ti.Tfbnspcirter's ID(Reserved 4 <br /> _�6 US EPA ID Number. <br /> 4 <br /> 5_77� <br /> Train�PoVtae*-Ph'O, <br /> CV 5. <br /> Transporter A Company Nam <br /> ne <br /> Ln D., <br /> .......... <br /> ed <br /> �Ef, t 1­ <br /> US EPA ID Number. <br /> 7. Transporter 2 Compa- Name <br /> Company t f <br /> 5 EPA ID Number <br /> 10� <br /> 9. Designated Facility Ncme and Site Address <br /> Crosby&overbw g�, <br /> N <br /> )Z 32 6' <br /> ce IWO W I 7th street CI i <br /> 0 :,14. Unit—u- nng R 12. Containers 11 To ,l I Y-�q�a <br /> Name,Hazard Clasi,and ID Nwriber) No. T pe Quantity <br /> 11. US DOT Description(including Proper Shipping Narn <br /> Wit Vo <br /> JZ 0. <br /> Nj- <br /> G 6,*ASM A <br /> FLAMA A 11- Q.� <br /> C�i 'k <br /> N <br /> co <br /> cli State" <br /> A <br /> c. <br /> EPA/O 4 <br /> 00 <br /> Lu d. h, <br /> -EPA/Of ii <br /> Lu <br /> `d Ab <br /> �H­dl; <br /> an .1 <br /> an <br /> Lu AA <br /> 77777177� <br /> - v7O'lAclaitiahal Descri oiwral.Listed Above�,­-.;,,. <br /> Z -X, <br /> pfl8rii <br /> e.,MR2, <br /> X 4�­ <br /> 0 <br /> 1. X_ <br /> NOU <br /> g <br /> Lu iT V, M1 <br /> V,L�­ <br /> I q V "d <br /> De <br /> 5 ET <br /> Z - Special Handling Instructions and Additional Information ./5. PjC(:�Qjj Rd <br /> 0 Sit <br /> CA <br /> Z <br /> #909 '07 <br /> R f <br /> d are classified,pocked, s <br /> 16. GENERATOR'S CERTIFICATION. I hereby declare that the contents of this consignment are fully and occui=ciiely described above by proper shipring name on <br /> marked,and labeled,and are in all respects in proper condition for transport,by highway accoycling.to applicable international and notiona government eeguations, <br /> degree v":'determined to 6e,e conomicaH <br /> m in place to reduce the volume and taxiciZ of waste generated to the dog I ha a a health <br /> If I arm a large quanti generator,I certify that I have a pi=* .disposal currently available to me which-minimizLs the present.and future threat to hum n <br /> a- practicable and that I tKave selected the practicable method a-77'recitment,storage,01 <br /> a z,if I am a small quantity generator;.l have made a good faith effort to minimize my waste generation and select the best.waste mo.nagement method..t.hot 4 <br /> and the environment;01 <br /> available to me and that I can afford. <br /> Signature' f Month Day Year <br /> Pr 1,nge /Typed Nam m <br /> U 10j) "I ITI,111�- <br /> _Z :,7 4!11 <br /> F.f—M.1.6Z <br /> 7 17 Transporter I Ac�nowledge rent of Rec month Day Year <br /> R Signature 4 <br /> 4 Print J/Ty d <br /> LU <br /> S '77, <br /> Lu P <br /> u_ I B. Trans or owledgemeni of Receipt of Materials Month Do eor: <br /> Day <br /> 0 Printed/Typed Name <br /> T <br /> cn E <br /> R <br /> 19. -Discrepancy Indication Space <br /> F <br /> Z A <br /> C <br /> exceps as noted in Item 19. <br /> 20. facilitY Owner or OeeraLor Certification of receipt of hazardous materials covered by this manifest r Month Day Yeai <br /> Signature <br /> T Printed/Typed Name <br /> UNIFORM <br /> HAZARDOUS <br /> WASTE MANIfEST <br /> ;r _r, am M� cl&.s� <br /> Mailing <br /> 3 Generator's Name and A <br /> U i ;d astern r <br /> jM Sheila <br /> F5 <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/991 Yellow: GENERATOR RETAIN$ <br /> EPA 8700-22 <br />