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Please print or type.(Form designed for use on elite(12-pitcheriter.) ` Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mannest Tmckin Number <br /> WASTE MANIFEST CAO983672601 1 1-800-458-1760 000940476 SKS <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> CITY OF LODI <br /> 1331 5 HAM LANE ATTN ROGER <br /> 1. CA 95240 <br /> Generators Phone: 209-333-6830 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> TY—TYSYSTEMS. INC. TXR000050930 <br /> 7.Transporter 2 Company Name , ._. _-._.__.._..,_.._.._.._..____. - U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, INC. 000760 U.S.EPA ID Number <br /> 6000 88TH STREET <br /> SACRAMENTO CA 95828 <br /> Facility's Phone: 916-386-4913 CA0000084517 <br /> ga, 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM <br /> and Packing Group(i any)) No. Type Quantity WtNol. 13.Waste Codes <br /> X X, 1HAZARDOUS WASTES LIr]UID, .?. 0. 5. OF G 0039 134 <br /> 9 NA3082 FO III <br /> s <br /> 2 Z. <br /> P <br /> FIVE <br /> 3 4 Z-008 <br /> 4. <br /> LODI <br /> MUNICR'LL,P <br /> VICE CENTNT <br /> ER <br /> 14.Special Handling Instructions and Additional Information SK TRCK1111109079334 0033523440 0000370797-0752-25 - - - <br /> i v,. c �. , ,.:...it ,E e,. ,, -.:• wbm,«xm.. ..:;:.✓... .w � s: .�.uw.r.,fri�+-vu.^:ArTaa.�,.w,F«s.._ . L, ::.„.. ,...... ..,.. <br /> 'ARR <br /> ERE <br /> AUTHR <br /> LICENSED <br /> SUBSEGIIIENT <br /> 15. GENERATOR'SIOFFE OR'S CERTIFICATION: Iherebydeclare that the contents of this consignment are fully and accbfatey described above by Ne 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 minimizabonAmept identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ff I am a sm nbty generator)is We. <br /> GenemtolslOffev's Printed7fyped.. me , Signatum P Month 77Day Year <br /> 16.International Shipme <br /> ❑Import to U.S. ❑Export from U.S. Port of entryledt: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TmnsporterAcknowledgment of Receipt of Materials <br /> C TransportertPdritedrryped Name Signature Month Day Year <br /> Na -34Ac <br /> Q Transobner-71pFinteat iypea Name _ Month Day Year <br /> C <br /> r <br /> j18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type —❑12esidue ❑Parfial Rejection El FUR Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facllity(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Faciliys Phone: <br /> uU 18c.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 hazardous waste treaunent disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification 91jeceipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pdntedrryped Name Signature Month Day Year <br /> I jj-14=12-7161-7 11 <br /> EPA Form 87OO-22(Rev. -05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> 1)0000£35 2) 3) 4) <br />