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I-L(I-,-)I <br /> a P1889e pont Or type.(Form designed for use on elite(12-typewriter) Form Approved.OMB No.2050-00: <br /> UNIFORM HAZARDOUS 1.Generator ID Number f ` . 2.Page 1 of 3.EmergencyResponse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 -800-468-1760 OOy 74377 SKS <br /> 5.Generator's Name and Mailing Address Generators Site Address(ifdiferent than Mailin address <br /> ITY OF LODT g <br /> s31 S HAM [ANY: ATTN RANDY LAENNY <br /> ODI CA 95240 <br /> Generators Phome2l)7-.133 -6630 <br /> fi1km, EffflN"STEM;:, nw, U.S.EPA ID NumberTXRtI0005093() <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS, INC. ;;007(;0 U.S.EPA ID Number <br /> 6000 88TH STREET <br /> Facllitys Phone: SVR.AKENT0 CA 95828 <br /> 916-3)s6-491tt CA00000845.17 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Clens,ID Number, 10.Contmners 11.7otal Q.Unit <br /> HM and Packing Group(If any)) No. Type Quantity Wtival. 13.Waste Codes <br /> ZARDOUS .HASTE, LIQUID, N, 0, S. F i 7039 3$ <br /> o NA3082 IPG II ( DO 9 <br /> I <br /> w 2. <br /> 0 g <br /> 3. <br /> E'lA,7 22 - <br /> 4. U9 t " 0?:: LOU <br /> kro1.!i:'`: „^E <br /> 14;Special Handling Instructors and Addittonal InformalTRCI(�110569051 0039OS1989 00003±0ry97 0920 )4 <br /> iER6#1^, : <br /> X AUTHORIZED TO RETAIN L(CENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,ard are classified,packaged, <br /> marked and labeledfplacarded,and are in all respects in proper condition for transport according to applicable international and national governments]regulations,If export shipment and I am the Primary <br /> Exporter.I certify that the contents of this consignment conform to the tens of the attached EPAAcknowlecigmem of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I ag)a small quardi 4enera or ms true-� <br /> Generators/Offemr's PrintediTyped Name Signature .c: Month`, Day (Y,esE, <br /> s 16.International Shipments <br /> ❑Import to U.S. LiExport from U.S. Pon of enbylexit <br /> Transporter signature(for exports ontyk Date leaving U.S.: <br /> TransporterAckrrowladgmenl N Receipt fMateials <br /> O�,Tmnsporter 1 I'miecirryped Name• / f• ��/ /' Smgnaum - Month D Y <br /> O <br /> y ._ -fir /i' t r ✓/F j . _ r/ U L`� � Ft,? <br /> Z Transporter 2 PrintedF1'gpetl Name } Q/ <br /> Signaum Month Day Year <br /> K <br /> f_ <br /> 4. 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity, El Type ❑Residue ❑Panel Rejection ❑Ful1 R ed'wn <br /> Manifest Re <br /> 78b.Alternate Facility(or Generator) fa enee Number. U.S.EPA ID Number <br /> J_ <br /> V <br /> rr,Q Facilitys Phone: <br /> U.1 18c.Signature mAltemale Facility(or Generator) <br /> 4 Month Day Year <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 4. <br /> LP.n't'eLd/TyP!1d <br /> signFacili n or Operator.Certification of r ipl of hazardous materials covered by the manifest except as noted In Item 18 <br /> e <br /> _rf Signaturei'll Da Y r} <br /> 7•%V��ttl-i <br /> V-2;(Rev.3-05) Previous.edNons are obsolete. <br /> 4 ! DESIGNATED FACILITY TO GENERATOR <br />