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OF <br /> NO -HAZARDOUS WASTE MANN QST <br /> �� <br /> Please print or type (Form designed toy use on elite(12 pitch)typewriter) - _ 2 Page ll <br /> NON-HAZARDOUS71.G.n.rtr`sIJSEPAIDNo. ManifestDocument No. rj11LEO ofWASTE MANIFESTCAD: 982 508 251 <br /> 3.Generators Name and Mailing Address <br /> Unified Western Grocers — Attn: .Pat Guillermety <br /> 5200 Sheila Street, Commerce, CA. 90040 <br /> 4.Generators Phone{ 320- 264-5200 _ <br /> S.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 <br /> 7.Transporter 2 Company Name 8. .US EPA ID Number - C.State Transporters ID <br /> r D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number E.State Facility's ID <br /> Remedy Environmental <br /> 3200 E. Frontera Street F.Facility's Phone <br /> Anaheim CA. 92806 CAL 000 200 500 714-630-2307 <br /> 12. Containers 13. 14. <br />` 11.WASTE DESCRIPTION Total Unit <br /> k No. Type Quantity Wt.Nol. <br /> a <br /> NOIR—HAZARDOUS. WASTE LIQUIDS <br /> G b. <br /> E REMEDY SICARONMENTAL SERVICES Orly <br /> N aceapts Now40mu4om weed r eeyd>.bie - <br /> E <br /> R c. oowtahted the tea: <br /> A <br /> T Total vks: <br /> 0 <br /> W R d. DocutlaMt ar MMISISt N: <br /> H.Handling Codes for Wastes Listed Above <br /> G.Additional Descriptions for Materials Listed Above - - - _ <br /> a.) non—hazardous water //;- <br /> 10 <br /> PROFILE #04--HMT-01-069 <br /> Q � @ .•cam-��-caP <br /> L Q 15.Special Handling Instructions and Additional Information Job. Site' Stockton Facility <br /> E _ .' 1990 Piccoli Rd. <br /> Z GLOVES & GOGGLES -Stockton, CA. 95215 <br /> I <br /> F Z : Emg. #909-889-5607 <br />�. i <br /> MAW <br /> 16.GENERATOR'S CERTIFICATION:1 hereby certify that the contents of this shipment are fully and accurately described and are in all respects i <br /> in proper condition for transport.The materials described on this manifeat are not subject tofederalhazardous waste regulations. F <br /> t <br /> Date � <br /> f X ntedrryped Name Signature Morirh Day oYear 1 <br /> Tl 17.Transporter 1 Acknowledgement of Receipt of Materials Date I <br /> Print <br /> edrTyped Name Signature Month Day Year <br /> 18.Transporter 2 Acknowledgement of Receipt of Materials Date ,1 <br /> Printed/Typed Name Signature Month Day Year <br /> RE i <br /> Il. <br /> 19.Discrepancy Indication Space <br /> f F <br /> f A <br /> 20.Facility Owner or Operator,Certilication of receipt of the waste materials covered by this manifest,except as noted in item 19. <br /> { <br /> L Date <br /> T P yped Name Si re - Mon Year <br /> ' <br /> v <br /> F-1402002, LABELAASI'ER(&(W0)821-5808 www.W)slmaster.com �PRINTED ONRECYCLED PAPER� Rev.3195 <br />