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b✓��� 5SL SK SHIP# e13548W5 II�IIIIIII�II�II�III�IIIIIIIIIIIIIICI ./ <br /> Please print or type.(Form designed for use on elite(12-pitch)g'pewriter.) 0043738475 K S <br /> FormApproved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2Page taI 3.rL�','p'��qp����RgsppqaA�se Pryppe 4.Mallwat TneNln Number <br /> WASTE MANIFEST TXR0000Bii?0�i ( t"".J�'Y': H�ry^I/h-@ 004.3.13847 g SKS <br /> 5 Generdlws Name and MatlmgAddress GenerelafsSileAddress(UdiflerM than maairg address) <br /> SAFETY-LEEN SYSTEMS, INC. SAFETY—KLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> tsm lohWMdm: 309-545-1011 SAL TDA CA 95368 <br /> 8,T Kr-1.Neme U.S.EPA ID Number <br /> �r�rlYar—YYJ_ .�hlNV SYSTEMS, INC. TXRA00081205 <br /> 7.Tmnspoder 2 Compwry Name U.S.EPA IO Number <br /> a.Deslguted Family Name and SiteAddress SAFETY—KLEEN OF CALTFORNIA, INC. US.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK CA 94550 <br /> 510--795-4400 C0988B874f8 <br /> Fao'Glys Phone: <br /> ga. 9b.U.S.DOTOesalplton(including PPOWShlpping Name,Ha and Gass,ID Number, 10.Lan6iners <br /> HM andPackig Grouptam)) Il.iow I 12Uni1 73.Wade Codas <br /> No. Type Quantity WLNOI. <br /> t• NDN-RCRA HA'_ARDOUS WASTE, LIQUID TT G ?PT <br /> o (USED OIL) <br /> w <br /> 2 del S75 <br /> 3. <br /> 4. <br /> 14.Spedal HaacYinglnsWftmand AdOmalln(omatlon TSD:EVG SAL CSG• <br /> P4 HR EMERGENCY it!-8'130-468-1760 (SAFETY—KLEEN) <br /> v PLITHORT7ED To RETAIN 1_TrNG_ SFQLj_NT CARRIERS AS NECESSARY <br /> 15. GENERATOR'S/OFFEROWS CERTIFICATION:I hereby declare ghat the comenlsof thismMlgmnenl are hAyand Iyde crRed above by the plopefshicong Mme,and arc classified.packaged, <br /> marked and labaled/plaumed,and are in all respects toproper bon for transport according to applicable lnlamafim .nL NgovammenUl regulalons.lfeapad MipmeNandlam the Primary <br /> Eppder,Iwgfy[hat 9m mnlents of this cauignmentaMom to the leans of Ne attached EPAAdmoaledgment of Co L <br /> Icomly Nalthawasle minimization salement(debibiedin40CFR26227(a)of lama lagequantllygeneraror)dr(b)(' m matl quantity generaM)Lswa, <br /> ereta'sl0lfemes Pdnledrryped Name Signature 0, Day YMr <br /> 07 <br /> .International Shpmen6 <br /> z ❑Impadto U.S. ❑Eapa1(ran U.S, Part wfiU.S. <br /> TreMpmersi¢taNre 0w exports only): eating U.S.: <br /> tl�w 77.T2 nspodarAckvadedgment of Receipt of Materials <br /> T der l PM[s IrTyped Name <br /> O SiD'alum Monty Day Year <br /> sora } Z <br /> G MAMclooner <br /> 21RvIect/TypecName Signature Moral Oay BM <br /> 18,Discrepancy <br /> 18a.Dwepancy Indication Span 11 Quantity E]Type ❑Resale ❑Partial Ra(ecdon El Furl Rejection <br /> 18b.Alternate Facluy(w Generator) Mutest Reference Numhen — <br /> U.S.EPAIDNumber <br /> J <br /> LL <br /> MAR 2 2 201 <br /> FWWs Pzmne: <br /> w 18c.SigMlum afPllemab Faddy(orGenerNar) <br /> 2 <br /> h19.Hazardws We Relent Management Method Codes(i.e.,codes forhazardas waaU aaabrerA dspasal,and raryd'ageysteM) f,•„ _ <br /> wo ,, o 2 3 4 <br /> 20.Dwiignated Fec4Ry OvmwwOpemtor,CeNFuallanofrecaiplofharaNasmatMals remdby Nemanifemum Med 8e s <br /> Pon#TypedNameA4 <br /> F 91 <br /> Monty Day Year <br /> pop &ggL <br /> 75kP <br /> EPA?o1m�SG00�2(Rgv�2-05�Previous edllionsare obsolete. DESIGNATED FACILITYTO DESTINATION STATE(IF REQUIRED) <br />