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1�`AZARDOUS WASTE MANI: j S <br /> NO Z <br /> Please print or type {Form designed for use on elite(12 pitch}typewriter} Manifest 2.Page 1 <br /> NON-HAZARDOUS 1.Generator's US EPA 10 No. Document No. 50513 <br /> WASTE MANIFEST CAD.982 508 251 Of <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( 3D3 264-5200 <br /> S.Transporter 1 Company Name S. US EPA ID Number A.State Transporters 10 <br /> Haz Mat Trans Inc. CAT 080 012 800 B.Transporter t Phone 909-'889-5b07 <br /> 7.Transporter 2 Company Name 8: US EPA ID Number - - C.Sate Transporters ID D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number E.State Facilkyrs ID <br /> Remedy Environmental <br /> 3200 E. Frontera Street F.FaalrtyPa Phone <br /> Anaheim CA. 92806 CAL 000 200 500 323-268-5056 <br /> _ - 12. Containers .. 13, 14. <br /> 11.WASTE DESCRIPTION Total Unit <br /> ..- No. Type Quantity tN1.NOE. <br /> a. <br /> f 17� vg� 67- <br /> NON--HAZARDOUS WASTE LIQUIDS . <br /> G b. <br /> E <br /> N <br /> E <br /> R c• <br /> r A <br /> T . <br /> 0 <br /> R d. <br /> Ll <br /> G.Additional Descriptions for Materials Usted Above <br /> a.) non-hazardous water <br /> n . <br /> 7 PROFILE #04—HMT-01-069 , <br /> ib <br /> a � <br /> 14 15.Special Handling Instructions and Additional Information• Job Site• Stockton Facility <br /> a <br /> _ 1990 Piccoli Rd. <br /> Z GLOVES & GOGGLES r 'Stockton, ' CA.' 95215 <br /> D <br /> zIF # — <br /> 1fi.GENERATOR'S CERTIFICA'RON: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 matenals described on this manifest are not subject to federal hazardous waste regulations. <br /> Date <br /> PrirWgiW Ped Name Si C r nth Day Year <br /> Z 107 1CGP !: <br /> R17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> P' ypedName Signa a Month Day Year <br /> s i +�/�C��L �� . 2 O7 Pk <br /> P Date <br /> O 16.Transporter 2 Acknowledgement of Receipt of Materials <br /> Printed(Typed Name Signature Month Ray 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 manliest;except as noted in item 19: - <br /> L - Date <br /> T � Sig ►�qir y Year <br /> F-1402002 „LM A571]L�{800}B21�i808 www.fabelmaster.=n 0%PRWMoNFWY=PAm FA__■.ra-„- Rev.3195 <br />