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NOo4 HAZARDOUS WASTE MAM iST <br /> Please print or type (Form designed for use on elite(12 pitch)typewriter)' Manifest 2,Pagel <br /> NON-HAZARDOUS 1.Generators US EPA ID No. Document Mo. � 7 <br /> WASTE MANIFEST CAD 982 508 251 `r of <br /> 3.Generators Name and Mafiing Address <br /> Unified Western Grocers - Attn: Pat Guillermety <br /> 5200 Sheila Street, Commerce, CA. 90040 <br /> 4.Generator's Phone( 323 264-5200 - <br /> 5.Transporter 1 Company Name 6. US EPA ID Number - A.State Transporters ID <br /> Haz Mat Trans Inc. CAT 080. 012- 800 B.Transporter 1 Phone 909-889-5607 ' <br /> 7.Transporter 2 Company Name B. US EPA ID Number .C.State Transporters ID <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10. - U5 EPA ID Number - E,State Facility's ID , <br /> Remedy Environmental <br /> 3200 E. Frontera Street F.Facility's Phone <br /> Anaheim CA. 9280b CAL 000 200 500 714-630-2307 <br /> 11WASTE DESCRIPTION 12. Containers 13. 14. <br /> . <br />� Total Unit <br /> No. 1 Type Quantity Wt.NcA.. <br /> a. . <br /> 7r <br /> NON-HAZARDOUS-WASTE LIQUIDS <br /> 3� <br /> G e <br /> N <br /> E - <br /> R c. <br /> A <br /> 4 T <br /> O <br /> R d. <br /> W mm FNViR LS O <br /> is i d0 <br /> Cl) w•atudexcmded <br /> iQ G.Additional Descriptions for Materials Usled Above �, i . des fo astes Listetl Above <br /> 5 <br /> N a.) non-hazardous water 7. pe 0 1571/4 Tangy value 15,,,15,,,?Q 3 <br /> 0 PROFILE #04-HMT-01-069 okcnM •r l�ifellkaR M: �Z S41 <br /> E N 15.Special Handling Instructions and Additional Information ` <br /> Q Job Site: Stockton Facility . <br /> _ 1990 Piccoli Rd. <br /> E Z GLOVES & GOGGLES Stockton, CA°. 95215 <br /> FO <br /> ZAging-889-S607 <br /> 16.GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment are futiy and accurately described and are in all respects <br /> in proper conditian for transport.The materials described on this manifest are not subject to federal hazardous waste regulations. <br /> E <br /> Date <br /> ' Printed7Tjyped Name / Si nature ,, Month Day Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Dale <br /> Ray <br /> A P=ee e Sign ur Month D Yer <br /> IN <br /> SS4 <br /> p18,Transporter 2 AcknowAdgement of Receipt of Materials Date <br /> TPrinted/Typed Name Signature Month Day Year <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 /> L Date <br /> rint yped Name Signa Month Day Year <br /> T P �� <br /> 621-5808 www.W)dmaster.com Rev.3195 <br /> F14 ED 2002 L�BE[I"�ASTEA®(800) eftir+rEU P�(� Eu,•rr,m, <br />