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'�jless print or type.(Form designed for use on elite(12-pitchowriter.) • form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page i of 3.Emergency Response Phone 4.Man et rae trig umbo <br /> WASTE MANIFEST <br /> CAD98367260f. 1 1-890-468-1780 (� 9t89 SKS <br /> 5.Generators Name and Mailing Address Generator's She Address(if diHeremman mailing address) <br /> CITY OF LODI <br /> 1331 S HAM LANE ATTN ROGER <br /> LODI CA 93240 <br /> Generators Phone: 209-333-61630 <br /> BSt���PYLC �PmYSTf,M&, INC U.S.EPA ID Number TXROOOOS0930 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, INC. 000760 U.S.EPA ID Number <br /> 6000 SETH STREET <br /> SACRAMENTO CA 958218 <br /> 916-386-4913 CA0000064317 <br /> Fadlity's Phone: <br /> ga, 91h.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(f any)) No. Type Quantity Wtival. 13.Waste Codes <br /> X 1HAZARODUS WASTE, LIQUID, VO. S. , D039 134 <br /> 0 9 NA3082 PG III (DO39)(ERG#171) <br /> AOUEDUS BRAKE SOLUTIDN(8. 3#/GAL} S <br /> 2. <br /> 3. E FEB - 5 2007 <br /> CITY OF <br /> 4. <br /> 14.Special Handling Instructions and Additional Imormatlon SK TRCY#108061838 003335908!-00-)0-3-7-0,27-7-070-4 2! <br /> SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 15 GENERATOR'S/OFFEROR'S CERTIFICATIONI I hereby declare that the contents of thls consignment am fully and accuratelydescdtiehabove byAhe proper shipping name,and are daseified,packaged, <br /> marked and Iabeledlplacarded,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 conlonn to the terms of the attached EPAAcknowledgmenl of Consent. <br /> I certify that the waste minimization statement idenCified in 40 CFR 262.27(a)(b I am a large quantity generator)or(b)(RI am a small quantity generator)is true. <br /> rslOBero s Pnntedfryped Name _ . _ Signatu _.? Month Day Year <br /> 10 Pr� 107 <br /> —r16.International Shipments <br /> F ❑Import fo U.S. ❑Export from U.S. Port of enhylexk: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> he Transporter 1 Pnntedflyped Name Signature 4: / Month Day Year <br /> 4 Transporter 2 Pdnted/Typed Name Signature Month Day Year <br /> a <br /> r g, <br /> 18a Discrepancy Indication Space ❑ Quanfity ❑Type 1:1 Residue ❑Partial Rejection ❑Full Releclim <br /> Manifest Reference Number: <br /> - � 186.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ra+. Facility's Phone: <br /> W l8c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazallous haste treatment.disposal,and recycling systems) <br /> 1. <br /> H1 a 1 2. a. 4. <br /> 20.Designated Fad' ner or Operator:CerfificalklDokeesipt of hazardous materials covered by the manliest except as noted in Item 188 <br /> Pdnted/Typad Signal re Month Day Year <br /> EpF 1 l� <br /> 'PP606H3Yg7�Q22((Tey.3-05) Previous edi rs are obsolete. 4) DESIGNATED FACILITi(FTO GENERATOR <br />