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ll-ILI SSL SK SHIP# 2.08675 IIIIIIIIIIIIIIIIIIIIIIIIII 111111 <br /> Please print or type,(Font designs for use on elite(12- tch 0 0 4 3 7 3 b 4 7 S K S <br /> 9 )h'Pe�iter) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator lD Number TXR000® li?lfl5 2.Paga(i e< 3.`c�RospoAse P.inne� 4.Manifest racking Number <br /> WASTE MANIFEST I S1NNI�NkYt3 1/h 100437384 <br /> o wA7 <br /> (� <br /> S.Generator's Name and MaAing AtldrAddressGenerator's SReAddress(d gent than malting address) I� <br /> SAFETY <br /> —KL5EN SYSTEMS, INC. SAFETY—KL.EEN .SYSTEMS, INC, <br /> BOX 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Ph'": R09-545-11811 1 SALIDA CA 9536A <br /> B.Tr�e�r�Caggdni fame SYSTEMS, INC. U.S.EPA ID Number <br /> t�1'k Y���EEN , TXR0000812l <br /> 7,Transporter 2 Company Name US.EPA ID Number <br /> 8,Designated Facility Name and She Address SAFETY—KLEEN OF CALIFORNIA, INC. U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK rA '1r}560 <br /> CAD980687418 <br /> 510-795-4400 <br /> lsPhare� <br /> be, St.U.S.DOT Description(InUWIre Proper Shipping Name,Haard Class.O Number, 10.Costainors <br /> HM and PacMng Group 9t any)) fl.TOW 12.Unit 13.Waste Codes <br /> No. Type Quantity WLNoI. <br /> lz 1. NOM—RCRA HAZARDOUS WASTE, LII2UID G ?P1 <br /> o (USED OIL) <br /> W <br /> v, <br /> 3. REC <br /> MAR 2 2 2016 <br /> a. ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> 14.Special Handling lnamctions andAdditmal Informal TSD:EV6 SA1. CS6e <br /> (00 <br /> 84 HR EMERGENCY #1-8W-468-1760 (SAFETY—KLEEN) <br /> AUTHORIZEDSK R Y <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedsm M the conWde of this consignment artfully and a de above by the poperahipping nazne,and are Gassifiad,packaged, <br /> marked and labeled/placarded,and are in all respects in proper cmMition for transport eccaWing b applicable intemalw aad on govemmemal regMations.If export shipment and I am the Primary <br /> Exporter, cenRy that the contents of This consignment conform b dm terms of the attached EPAAdmowledgmant of C m. <br /> cediy that the waste minimization statement identified in 40 CFR 282.27(a)(if I am a large quan0ly generator)or(b)(' m mall quantity generator)u Uue. <br /> eratorslOfferofs Pnrtte6Ty�Name Signature Month Day Year <br /> VV4 p] L&( l <br /> W.Internatl Shipments <br /> F ❑impart to U.S. ❑Export from U.S. Pat entryfedt: <br /> Transporter signature(for exports only): a vino U.S.: <br /> ,a 17.Trans"rAcknowledgmentaf RoWptof Mataisis <br /> OTrain net 1 PrintedNYped Nom,. Signature ,r Month Day Year <br /> rwsN of L <br /> poer2Pdn /ym / <br /> 4 Stitt <br /> Month Day year <br /> F <br /> i18.Discrepancy <br /> 183.Discrepancy Indication Space ❑ Cuantily ❑Type ❑Residue ❑Partial Relaction ❑Fut Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facallys Phone: <br /> W 18n Signature ofAftemale Facility far Generator) Month Day Year <br /> Q <br /> 2 <br /> W19.Haamous Waste Report Management Medved Codes tor,codes for hazardous nets treatment,disposal,and recycling systems) <br /> G 1. M 1 <br /> 2. 3. 4. <br /> 20.Designated FaGRtyOw erar Operator.Certification of mcelpt of hazardous materials covered by the manifest e s nae0 <br /> Name Signatu Month DayYear <br /> 07126 <br /> EPi Ill Re8-051 Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(F REQUIRED) <br />