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NQt4 ZARDOUS.WASTE MANIti <br /> Please print or type (Form designed for use on elite{i2 pitch)typewriter) Manifest 2.Page 1 <br /> NON-HAZARDOUS 1.Generators�50-3 <br /> Document No. of <br /> WASTE ACAD `3851 . <br /> 3.Generators Name and Mailing Address - .n; - <br /> ,Jnifiai' i�st�ra Grocers _ Atta:;?3t a ill rinet <br /> 5200 S'1{'_iia .3treat, Coin,aerce, .CA. 90040 <br /> 4.Generator s.Phone{ 32� 264-152010� <br /> US� 0 <br /> EPA 7D Number - A.State Transporters ID <br /> 5.Transporter 1 Company Name ., - CX l 530 .012 80 _ <br /> .,at. Tra zs, �j.EC- i +J B.Transporterl Phone. <br /> 7.Transporter 2 Company Name - e. US EPA ID Number C.State Transporters➢D <br /> D.Transporter 2 Phone <br /> E.State Facilitlls ID <br /> 9.Designated Facility Name and Sde Address -. .10. US EPA 11)Number <br /> lsfnv 3y Enviirai -np t�1 <br /> 3200 .x',`. Ia'raatara Street F.Faciii€ysPhone <br /> CA. 92805 CAI 000 200 500 71 -630-23�J7 <br /> t�I13:12�'il, . <br /> _ - 12. Containers 13. 14' - <br /> 11.WASTE DESCRIPTION Total 'Unit <br /> No. Type Quantity WE.IVoI.' <br /> a. <br /> _ o <br /> 40<d-1kZA_,:DO'JS :4ASTE LIQJZ <br /> G b. - <br /> E <br /> N <br /> E:, <br /> R c. <br /> A <br /> T <br /> W R d <br /> UF.1 ;4 <br /> Q _ H.Handling Codes far Wastes Listed Above <br /> G.Additional Descriptions for Materials Listed Above <br /> Cl) <br /> �1 Z0F1LEV #04-VIT-01.069. <br /> D <br /> N 15.Special Handling Itistructlens and Additional Information Si C$:J tacktan '3C. ltp <br /> Q 1990 ?I.ceoli I1. <br /> Z MOVES & GOGGLES. Stoctt�a,'. CA. 952115 <br /> Z E ag. #909-839-56177 <br />� 16.GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment are fully and accurately described and are in all respects <br /> in proper condition for transport.The materials described on this manifest are not subject to federal hazardous waste regolaii­s. <br /> Date <br /> flflfl y <br /> f PrintedlTy ed Name Signature Man D�y4_ <br /> kill <br /> Year <br /> !` j Al <br /> a ! Date <br /> R 17,Transporter 1 Acknowledgement of Reoeip[of Materials <br /> Signatu <br /> r ✓` Month Day Year <br /> A Priny d N me 1 �y/r, /qI�C] <br /> P Date <br /> 18.Transporter 2 AcknowWgement of Receipt of Materials - <br /> a <br /> R Pr ntedlfyped Name Signature- Month .Day. Year <br /> T <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> C20.Facility Owner or Operator;Certification of receipt ofthewaste materials covered'by this manifest,except as noted in item 19. ' <br /> � - <br /> t Month Day "Year <br /> Printedrryped Name Signature .,.. - <br /> F-1402002 LAKLMAS 0(800)6215809 www.labelmasfer.Com �FAJNM00NRECYCLED PAPER .■IN1FOw,ix <br /> .��N�nwcau,ur crwruv <br />