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SSL SK SHIP# 212064344 <br />Please print of tvoe. (Form designed for use on elite f 72-nitchl tvnpwdt,-r l P- Ann --,i nruR un )nrn_nnia <br />ElhlrnW21I .1 ) Previous editions are obsolete. DESIGNATED FACILITY TU UESTINATIUN S IRI t (It Ktl,1UIKt <br />Page 48 <br />r�r <br />Nil - <br />UNIFORM HAZARDOUS 1. Generator ID Number TX 8000081205 <br />2. Pag f 1 of <br />3 En cyRefppnsa Pkoag, 4 Nlalri#e( Tgck�rg�{ <br />1 �Fco-1 ItfRl <br />WASTE MANIFEST <br />O 8 8 J 2 g FLE- <br />5. <br />5. Generator's Name and Mailing Address Generator's Site Address (if different Um mailing address) <br />SAFETY-KLEEN SYSTEMS, INC. SAFETY-KLEEN SYSTEMS, INC. <br />PO HCl( 555 5050 SALIDA 9LUD <br />SRLIDA CA 9568 <br />-545-1011 SRLIDA GA 9S35B <br />Generators Phone: <br />6. NffiVWpWeSYSTEMS, INC. U.S. EPA Ip Number TXR000081205 <br />7. Transporter2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address SAFETY-KLEEN OF CALIFORNIA, INC. U.S. EPA 10 Number <br />6880 SMITH AVE. <br />NEWARK , CA 94560 <br />510-795-4400 CAD9808.87418 <br />Fadiity's Phone: <br />go. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Contalners <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Ouantity <br />Wt.Nol. <br />1. NDN-RCRA HAZARDOUS WASTE, LIQUID <br />TT <br />G <br />221 <br />(LISED OIL) <br />� <br />vd 1 <br />y�yo <br />W <br />2 <br />F7 <br />7Vt <br />3. <br />4, <br />EOR <br />r,riiro8 T�iAI't�l <br />14. Special Handling Instructions and Additional Information TED : EUG SAL CSG: <br />24 HR EMERGENCY #1-800-469-1760 (SAFETY-KLEEN) <br />SK AUTHORIZED TO RETAIN LICENSED SUSSEGUENT CARRIERS AS NECESSARY <br />15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accunptl§fly de dOed above by the proper shipping name, and are classified, packaged, <br />marked and labetedlpkecorded, and are in all respects in proper condition for transport according to applicable intern nd n not governmental regulations. If export shipment and I am the Primary <br />Fwoder. I certify That the contents of this consignment conform to the terms of the attached EPA Acknowledgment of C I. <br />I certify that to waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) am mall quantity generator) is true. <br />Ge 91 roc's dnt Name Signature on y year <br />-6 r z 1 <br />- r <br />16. International Shipments <br />: <br />❑ import to U.S. ❑Export from U.S. PA�aviys.: <br />= <br />Transporter signature for exports only):D <br />LU <br />17. Transporter Acknowledgment of Receipt of Materials <br />Li <br />Transpo 1 PrinledlTyped Name Month Day Year <br />IL <br />QTransporter2Pdntedlfy*Name <br />Signature Month Day Year <br />16. Discrepancy <br />18a. Discrepancy Induction Space El Quantity ❑ Type ❑ Resdue ❑ Partial Rejection FUII Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA Ip Numher <br />V <br />Fadli s Phone: <br />w <br />18c. Signature of Alfemate Facility (or Generator) Month pay Year <br />a <br />Z <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recyding systems) <br />0 <br />1. a <br />2. <br />3. <br />4. <br />20. Designated Farality Owner or Operator. Certification of receipt of hazardous materials covered by the manliest except as noted in Item 18a <br />Pdntodlf Name Signature Month Day Year <br />f i I t <br />ElhlrnW21I .1 ) Previous editions are obsolete. DESIGNATED FACILITY TU UESTINATIUN S IRI t (It Ktl,1UIKt <br />Page 48 <br />r�r <br />Nil - <br />