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MA It <br /> I4T <br /> NG. .-HAZARDOUS WASTE <br /> Please print or type (Form designed for use on elite(12 pitch)typewriter) 2.Page i <br /> Manifest <br /> NON-HAZARDOUS 1.Generator's US EPA ID No.' Document No. 52640—A of I <br /> WASTE MANIFEST CAD 982 508 .251. <br /> 3.Generators Name and Mailing Address _ <br /> Unified Western Grocers _ Attn: Pat Gullermety <br /> 5200 ShOl.a -Street, Commerce, CA. 90040 <br /> 4.Generators Phone( 323 ) 264-5200 A.StateTransporter's10 <br /> 5.Transporter 1 Company Name 5. US EPA ID Nurnber <br /> CAT 080 OIL 800 B.Transporter 1 Phone 909-889-5607 <br /> Haz Mat Tran ;, InC. C.State Transporters ID <br /> 7.Transporter 2 Company Name 8. - 'US EPA ID Number <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address <br /> 10, US EPA ID Number E.State Facility's ID <br /> Remedy Environmental F.Facility's Phone <br /> 3200. E: Frontera Street CAL 040 200 500 714-630-2307 <br /> Anaheim CA. 92806 12. Contalnrs'a 13. 14. <br /> Total - Unit <br /> WASTE DESCRIPTION Wt.NOI. <br /> 11.W Quart <br /> I No. Type /// <br /> a. <br /> NDN-HAZARDOUS WASIT LI UIDS L <br /> G b' <br /> II N . <br /> E <br /> R C. <br /> A <br /> T <br /> O <br /> R d. <br /> W <br /> Q H.Handling Codes for Wastes Listed Above <br /> G.Additional Descriptions for Materials Listed Above . <br />! to a.) non-hazardous water ' u ?, f -5 V' <br /> o PROFILE #04-H4T-01-069 <br /> Q15.Special Handling Instructions and Additional Information .job Site e- Stockton Facility <br /> _ 1990 :Piccoli Rd. <br /> Z GLOVES & GOGGLES Stockton; CA. 95215 <br /> i Z —#QnQ-8 - 6 <br /> f of this shipment are fully and accurately described and are in all respects <br /> 16.GENERATOR'S CERTIFICATION:I hereby certify that the contents <br />' in proper condition for transport.The materials described on this manifest are not subject to federal hazardous waste regulations. - <br /> i Date <br /> Printed(Typed Name Signature ' Month Day Year <br /> Date <br /> T 17.Transporter t Acknowledgement of Receipt of Materials <br /> A Pri pe Nam Sign r Month Day Year <br /> N AOCS <br /> a Date <br /> p 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printedfryped Name Signature - - -Month Day Year <br /> T <br /> E <br /> R <br /> 19.Discrepancy Indication Space _ <br /> F <br /> A <br /> C <br /> 20,Facility Owner or Operator;Certification of receipt of the waste materials covered by this manifest,except as noted in item 19. <br /> I L Date <br /> Ye <br /> IT P'n rrryped N me Signator ' „ n Oay O� <br /> i Y { - cieL <br /> r <br />' F-1402002 LABEI.T"eAS7'EA®(800)621-5808 www.labelmaster.com �PRINTED ONRECYCLED PnPEA reiwreowis Rev.3195-- <br />