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_ NOS, ZARDOUS WASTE M <br /> AN1. . T <br /> Please pr).nt or tyyb (Form designed for use on elite(12 pktch)typewriter) =Pae1.Generator's US EPA ID No. ManifestNON-HAZARDOUS Dooumer,t" 1i <br /> WASTE MANIFEST CAD' 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.Generator's Phone( 323 264-5244 <br /> 5.Transporter 1 Company Name 6.' �� U5 EPA 10 Number A.State Transporters ID <br />` Haz Mai Trans, Inc. CAT 080 012 800 S,Transporter 1 Phone 909-889-5607 <br /> U5 EPA ID Number C.State Transporters ID <br /> 7.Transporter 2 Company Name <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number E.State Facility's]D ' <br /> Remedy Environmental <br /> 3200 E. Frontera Street F.Facility's Phone <br /> r Anaheim, CA. 92806 CAL 000- 200 500 714-630--2307 <br /> - 12. Containers 13. 14. <br /> I 11.WASTE DESCRIPTIONTotal Unit <br /> No. Type Quantity Wt.NaI. <br /> i <br /> NON HAZARDOUS WASTE LIQUIDS <br /> G b. <br /> E Q ENTAL 81CRAIM Orb' <br /> Nbk <br /> LYt rs waterfex > <br /> R c. 1ea:11te <br /> A <br /> T Tool ufll"- +� <br /> O <br /> W R d. )wutmem or"�"�."~: 5 ZE D 6 <br /> QG.Additiona$Descriptions for Materials Listed Above / - - H.Handling Codes for Wastes Listed Above <br /> 5 a.) non—hazardous water � � <br /> { `~� <br /> C) PROFILE #04--HMT-01-069 <br /> Q15.SpqlVal Handling Instructions and Additional InfonnaGan Job Site: Stockton Facility <br /> _ 1990 Piccoli Rd. <br /> I` OGLOVES & GOGGLES Stockton, CA. 95215 <br /> Z Emg #909-889-5607' <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 loderaI hazardous waste regulations. <br /> l <br /> Data <br /> - Month pa Ye r <br /> ' <br /> PL 02Y ed Name tura C y <br /> 34 <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials y - Date <br /> R <br /> Print p9d Name <br /> f/� Sign r Month �Draay, Year <br /> N �I' T" i �V <br /> S <br /> f E) 16.Transporier 2 Acknowledgement of Receipt of Materiats Date _ <br /> T <br /> Printed/Typed Name Signature : Month Day. Year <br /> E e <br /> R <br /> 19,Discrepancy Indication Space , <br /> F <br /> f A <br /> C20.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 /> T Printed(Typed Name Signature Month flay Year <br /> Y I'S +tAa t <br /> F•1402002 f_A8ELAASTFR8(8X)621.5809 www.labelmaster.com �PAWED ONRtVYCLEDPAPERFAEEErownx Rev.3195 <br />