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SSL SK SHIP# 213157304 • (IIII I�I�I II(I'�II„) I'I' �II <br /> 0042554465 KS <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM VZA&IMli S 1.Gerwralor ID Number TXROOM 1205 2.Pagell of 4.Manifest Traer <br /> WASTE MANIFEST 0 04F6"6446 SKS <br /> 5. r Gerandofs Site Address HcIdmV thanmaitn address) <br /> "4�Cd aTEMS, INC. SAFETY— N SYSTEMS, INC. <br /> PO BOX 555 5050 SAL OR BLVD <br /> SALIDA CA 95368 <br /> Generator's Phone 209-545-1011 SALIDA CA 95368 <br /> 6.r9 1'``dRt_' SYSTEMS, INC. U.S.EPA IDNurretar TXR000082205 <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address — , U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK , CA 94560 <br /> 510-795-4400 � CAD980887418 <br /> Facility's Phone: <br /> ga, 9b,U.S.DOT Descnoton(mdudig Proper Shipping Name.Hazard Class,ID Number 10.Containers 11Total12.Unit 13,Waste Codes <br /> HM and Packkg Group(if any)) No. Type a A4Wol. <br /> o (USED OIL) <br /> cro <br /> W 2. +T _ <br /> IM 6J <br /> 3. <br /> FNVIRQNMENTAL <br /> 4' r HEALTH DEPARTMENT <br /> 14.Spacial Handling lnslmctionsandAddflional Information <br /> 24 MR EMERGENCY #1-800-468-1760 (SAFETY—KLEEN) <br /> SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare thalthe contents of this consignment are fully and acrd tlescrbed above by the proper stepping name,and are classified,packaged, <br /> marked and Iabeledlplacartlatl,and am in ah respect in proper condition for transport acoordirV ro applicable Polernati =at govemmental regclatbns.11 expert shipment and I am the Primary <br /> Exporter leer[[[y fiat the contents of this consigmnentcmbrm Wthe50rme of the attached EPA AckrioMedpmeni of i. <br /> I cerefy that the waste mmimizahon statement idenCead In 40 CFR 262.27(a)(it I am alarge quantity genmzlor)or(b) a srnd quantity geraretor)is from, <br /> Ge fs!06arons Pridedrived Name Signature Mordh Day 'mar <br /> A ta5 1 Y <br /> 18. tion hipnank ❑[ ort to U.S. ❑Export trent U.S. of entryledt:....._ <br /> = Transporter sgnaterre(for reports ony): iverg US.: <br /> 7+C 17.Transporter Acknowledgment of Receipt of Materials <br /> tr Trans r 1 Pr nted(Typed Nemec Sgnature Month Day Year <br /> Is. Of <br /> N <br /> Q.Transporter 2 FrmusliTyped Name Signature Month Day Yew <br /> V. <br /> 18.Discraparr0y <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejed. ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b,Alternate Facility(or Gm entrof U.S.EPAIDNumber <br /> v <br /> W Fadi Ph": <br /> ISo.Signature Of Alternate Facility(or Generator) Month Day Year <br /> H19.Haze ous Waste Report Management Method Codes p.e.,codes for hazardous waste treatment,dispose[,ant recycling systema) <br /> 0 1. Q 2. 3, 4. <br /> 20.Desgeated Facility 0wnerce0peroter:Canifl lremiiptm hazwdous i9iflerials cowed by the manifest excepts in prearn 18a <br /> daredrrtype Name Signature Monty Day Yesr <br /> -�.� �--- <br /> EFAfjTM3gftf 5 Previous edilionsareobsole e. liffRIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />