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N61vAZARDOUS WASTE MANt T <br /> Please print or type( Form designed for use on elite(12 pitch)typewriter) Manifest 2'Page 1 <br /> NON-HAZARDOUS 1.Generators US EPA ID No. Document No. of <br /> WASTE MANIFEST CAD 932 508 251' <br /> 3.Generators Name and Mailing Address <br /> unified Western Grocers - .Attn:-Pat Guiller-;tety <br /> 5200 Sheila Street, C&Aiierce, CA, 90040 <br /> f 4.Generalbrs Phone( 3253 264-5200 <br /> 5.Transporter 1-Company Name - 6. US EPA ID Number A.State Transporters ID <br /> Haz Mat Trans, Inc. CAT 030. 012 800 B.Tram porterl Phone 909-889-5607 <br /> - <br /> f3. US EPA 11)Number C.State Transporters ID <br /> 7,Transporter 2 Company Name ' <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address - 90. US EPA ID Number - E.State Facility's ID <br /> Remedy..Environ-mental <br /> 3200 E. Froatera Street F.PacilitirsPhone <br /> Anahei. , CA. 92806 - CAL OOQ 200. 500 714-637-2307 <br /> 12:-Containers 13. 14. <br /> Ic 11.WASTE DESCRIPTION 7ota1, Unit <br /> No Type Quantity Wt./vol. <br /> a. <br /> rB LIQUIDS 71f <br /> G b I <br /> E <br /> 4 N <br /> I R <br /> A <br /> T <br /> AU <br /> i <br /> a _ <br /> H.Handling Godes for Wastes listed Above <br /> G.Additional Descnptions for Materials Listed Above _ <br /> N <br /> a.) non-hazardous water <br /> O PROFILE #04—T,MH -=01--069 <br /> D <br /> N 15.Spe IHandlingInstructionsaanndAdditio Additional Information Job Site: Stockton Facilaty . <br /> Q 1990 Piccali Rd. <br /> Z GLOVES:& GOGGLES Stockton, CA. 95215 <br /> Q Egg.. '#909-889--5607 <br /> Z <br /> 16.GENERATOR'S CERTiFiCATiON:f hereby certify that the <br /> contents of this shipment are fully and accurately described and are in all respects - - <br /> in properconditionfor transport.,The materiats described an this manifest are not subject to federal hazardous waste regulations. , <br /> Date <br /> Month Day Ye <br /> Print WT ed Name S' urs t <br /> Date <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> g Month Day Year <br /> k p -Pr[nte e N me ,� �j Sin r 3 <br /> S '-� Data <br /> pi3.Transporter 2 Acknowledgement of Receipt of Mater els . <br /> R Signature Month Day Year <br /> T Printed/Typed. d!TYPed <br /> Name <br /> E <br /> R <br /> 19.Discrepancy Indication Space - - - <br /> F <br /> A <br /> 1- - 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 /> T Printed(fyped Name Signature - .Month Day Year <br /> Y <br /> + Rev.3/95 <br /> F•1402002 LAUIP;;1 S 0(800)621-6M vnvw.IabelmaSter.com PRINTED 014 RECYCLED PIPERrR nraNiw <br /> - - M IMNGSOYBEANuric r [6 INK - <br />