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7-185-01 <br /> 44 <br /> Please Aril or type.(Form designed for use on elite(12-pitch9wdtec) . Fomn Approved.OMB No.2050-0039 <br /> r UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manliest Tracking Number <br /> WASTE MANIFEST CAD963672601 1 11-800-4613-1760 1000826472 JJK' <br /> 5.Generator's Name and Mailing Address Gene r She Address to ditument than mailing address) <br /> CITY OF LODI CEIVE® <br /> 1331 S HAM LANE ATTN ROGER <br /> LODI CA 95240 <br /> Generators Phone: 209-333-6834 <br /> 6.Tmnsner I CompanyName U.S.EPA ID Number <br /> SAFEITY—KLEEN SYSTEMS, INC TAR000050930 <br /> 7.Transporter 2 Company Name MUNICIPAL SERVICE COMU.S.EPA ID Number <br /> It.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, ItX, 000760 U.S.EPA ID Number <br /> 6000 BOTH STREET <br /> SACRAMENTO CA 95828 <br /> Facility's Phone: 916-386-4913 CAOOOOO84517 <br /> ga, 91b.U.S.DOT Descripbon(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WLNOL 13.Waste Codes <br /> z X tHAZARDOUS WASTE, LIQUID, N. O. S. DF G D039 <br /> 0 9 NA30132 PO III 0039)(ER1311171) <br /> fOLJEOUS BRAKE SOLUTI014(8. 30/GAL) 00 J 0005 <br /> Z 2 <br /> W <br /> co <br /> 3. <br /> 4. <br /> 14,Special Handling instructors and Additional Information SK TRCKR107006673 0032823654` 0000370797 06e�: <br /> RETAINSK AUTHORIZED TO LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 15. GENERATOR'SIOFPEROR'SCERTIFICATION: I hereby declare that the conlents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are In all respects In proper condition for transport according to applicable International and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement Identified In 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(if I am a small quan' nerator)is true. <br /> Generators/Offeror's PdN dfrypd Name / Signature Month Day Year <br /> Vv 1016.International Shipments <br /> z ❑Import to U.S. ❑ xport Efrom U.S. �Portofentry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknoWd ceipt ment of Reof Materials <br /> QTransporter 1. ntellpel To igneture Month Day Year <br /> a <br /> fit <br /> Za Transporter d Name Signotmal P Month Day Year <br /> K <br /> r <br /> I18.Discrepancy .... <br /> 18a.Discrepancy Indicafion Space - — - —- <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Re/action ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> v <br /> rai Facility's Phone: <br /> 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 71. H1441 2, 3. 4. <br /> 20,Designated Fa cil Owner or Operator.Codification of receipt of hazardous materials covered by the manifest except as noted in Item 1 <br /> PdntedRype/ Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> 3) D NATED FACIl TO GENERATOR <br /> 1)0040839 2) <br />