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0 <br />SSL SK SHIP# 215663432 <br />1,......... .. 13.. 1. n -3..k, l..........:4... % <br />III VIIIIIIIII�IIIAINVIIIIIIForm A1111310ved. OMB No. 2050-0039 <br />0 0 <br />tvj 5q gTjj iggi rreviuus cumuntj we uuwwiv. LjQoj Ul'jjij CW rr ry v...v .....-....... ......—`.. ..�_.�-. <br />Page 17 <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />TXR0t�00�l1205 <br />2. Page 1 M <br />3. m Res se P <br />14. Manifest Tracking Number <br />0 0 4 7 6 4 4 7 L SKS <br />WASTE MANIFEST <br />5. Generator's Name and Mailing Address Generators Site Address (0 different than making address) <br />SAFETY-KLEEN SYSTEMS, INC. SAFETY-KLEEN SYSTEMS, INC. <br />PD BOX 555 5050 SALIDA BLVD <br />SALIDA CA 95368 <br />209-545-1011 SALIDA CA 95368 <br />Generators Phone: <br />"Tran er 3 Com n Name U.S. EPA ID Number T X ROOOOS 1205 <br />Sf�FETY-F�,�EN SYSTEMS, INC. <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Fadl4y Name and Site Address SAFETY-KLEEN OF CALIFORNIA, INC. U.S. EPA ID Number <br />6880 SMITH AVE. <br />NEWARK , CA 9456V1 <br />510-795-4400 CAD980887418 <br />Fadlil}+s Phare: <br />ga. <br />9b. U.S. DOT Description (induding Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers11. <br />Total <br />12. UnitHM <br />13, Waste Codes <br />No, <br />Type <br />and Packing Group (it any)) <br />Quantity <br />Wt,Nol. <br />1 NON-RRCRRA(USEDL�RAZARD13US WASTE, LIQUID <br />TT <br />6 <br />221 <br />c <br />Y <br />a <br />2. <br />fry1i <br />ui <br />[7 <br />AL G 07 5 <br />3. <br />r rr 1-r t <br />4. <br />14, Special Handting Insbnucixns and Additional Information TSD : EV6 SAL CSG: (>C) <br />24 HR EMERGENCY #1-800-468-1760 (SAFETY-KLEEN) <br />SUR5EQUENT CARRIERS 95 NECESSARY <br />SK AUTHORIZU TO RETAIN LICENSED <br />15. G£NERATOR'S10FFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name, and ere classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to appli le intemational and national governmental regulatons. If export shipment and I am the Primary <br />Exporter, I cerlily that the contents of this consignment conform to the terms of the attached EPAAcknawledgmen of Consuint. <br />I certify that the waste minimization statement identified in 40 CFR 282.27(a) (f I am a large quantity generator) b) (iflint a sma!I quantity generator) Is true. <br />Gen=tceslOfferors nledl7yped Name Sig"Month Year <br />/Day <br />r / <br />.J <br />t6. lntemalional Shipments <br />❑ Import to U.S. ❑ Export imrn U.S.rr Port of entrylexit: <br />Transporter signature (for exports only): D e le4wing U.S.: <br />LLJ <br />17. Transporter Acknowledgment of Receipt of Matenials <br />I.— <br />Trans015 net 1 Printed/Typed Name Signature Month Day Year <br />a <br />16 <br />a <br />Z <br />r rter 2 Pr ntedfiyped Name Signature Month Day Year <br />4 <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Allemate Facility (or Generator) U.S. EPA ID Number <br />_J <br />V <br />Facility's Plane: <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />a <br />Z <br />S219. <br />Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems) <br />ca <br />1. <br />2. 3. <br />4. <br />: "0 q <br />1 <br />20. Des gnated Facility Owner or Operator Certification of receipt of haze ous materials covered by the manifest except as noted in Item 18a <br />PrintedlTyped Name Signature Month Day �Yjeaarr <br />r I!r nc`f'a111 C1Cr'1' <br />tvj 5q gTjj iggi rreviuus cumuntj we uuwwiv. LjQoj Ul'jjij CW rr ry v...v .....-....... ......—`.. ..�_.�-. <br />Page 17 <br />