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7-185-01 <br /> Please. rint or type.(Form designed for use on elite(12-pitch writer.) . Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest)reckin Number <br /> WASTE MANIFEST CAD983672601 0 0 0 4 7 4 0 2 3 SKS <br /> : -46s- .7ao <br /> 5.Generators Name and Mailing Address Generators Site Address(it different than mailing address) <br /> CITY OF LODI <br /> 1331 S HAM LANE ATTR ROGER <br /> LODI CA 95240 <br /> Generators Phone: 209-333-6834 <br /> 6.Tranthat 1 Compan am U.S.EPA ID Number <br /> SAFT-TY-KLEN SYSTEMS, INC. TXRO00050930 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS, INC. 044764 U.S.EPA ID Number <br /> 6400 88TH STREET <br /> SACRAMENTO CA 95828 <br /> 916-386-4913 CAOOOOO84517 <br /> Facility&Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> and Packing u 13.Waste Codes <br /> HM 9 GroP(�ran Y)1 No. Type Quantity Wt.Nol. <br /> 1 ;1)YARDOUS UASTE, LIQUID, N. O. S. OF 8 D039; 134 <br /> o MA3082 FG III (D039)(ERD11171) <br /> ",UEOUS PIRAKE SOLUTION(8. 3#/6AL) f S <br /> w <br /> w z. <br /> cD <br /> 3. <br /> 4. <br /> 14.Special Handling lnstmctions and Additional Information SF( TRCX#108318614 0033892786 0000370797 0716 25 <br /> NECESSARYSK AUTHOR17F TO RETAIN LICE14SED SIMSEGUENT CARRIERS AS <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,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 conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste.minimization statement i5aptified in 40 CFR 262.27(a)(f I am a large quantity generator)or(b)(61 a a aIL uantity generator)is hue. <br /> Generator's/Offerors Pd tedfry ed Name ignature ( Month Day Year. <br /> J16.Inte ational Shipments - <br /> 1- ❑Importto U.S. ❑Export from U.S. Port of enhylexit: <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> C Trapsporter1 Primecirryped Name Signatu Month Day Year <br /> QTransporter 2 Pdntedl typed:Name Signature Month Day Year <br /> K <br /> h <br /> TI... <br /> 18 Discrepancy <br /> 16a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Resitlue ❑Radial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Facility's Phone: <br /> fee.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> S2 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. H1.41 -- 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Cerlificatigilof receipt of hazardous materials covered by the manifest except as noted in Item <br /> Pnr4edrryped Na Signature Month Day Year <br /> e'er V 7 <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACI LITY TO GENERATOR <br /> 1)4400839 2) 3) 4) <br />