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7-185-01 <br /> Please print or type.(Form designed for use on elite(12-pitch*riter.) . Form Approved.OMB No.205041039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAD983672601 2.Page 1 of 3.Emergency Response Phone 4.Menifeat Treckin Number <br /> WASTE MANIFEST 1 1-800-468-1760 001034324 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(ff different than mailing address) <br /> CITY OF LODI <br /> 1331 S HAM LANE ATTN RANDY LAENNY <br /> LODI CA 95240 <br /> Generators Phone: 209-333-6830 <br /> s.�n riEfETWeSYSTEMS, INC. U.S.EPA ID Number TXR000050930 <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 88TH STREET <br /> SACRAMENTO CA 95828 <br /> Facllity's Phone: 916-386-4913 CA000OO84517 <br /> gra 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(If any)) - No. Type Quantity Wt.Nol. 13.Waste Codes <br /> X ' HAZARDOUS WASTE, LIQUIDS. DF G D03 134 <br /> p a 34ncna^ TDI- TTT <br /> W <br /> c9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional nformation SK TRCK#109343013 OOi. 00370797 0811 c <br /> '}ERG#171 <br /> fTAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 15. GENERATOR'SIOFFEROR'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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and l am the Primary <br /> Exporter,I certiy that the contents of this consignment conform to the tons of the attached EPAAcknowledgment of Core <br /> I certity that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b) a sma quantitygenerator)is true. <br /> GeneratorslOfferor's Pnnted(Typed Name <br /> 'SignaWre /.' Month Da Year <br /> ,. , 1. t.T,i -11 ,'G-1, �e:{.; -.. I Cr"l� _ 01 Zia.? <br /> 16.Intematioai Shipments <br /> _ ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Transporter signature(far exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> KTransporter 1 Pn typed Name Signature <br /> 0 9 Month Day Year <br /> O� / 208 <br /> z Iransporter2 (Type Name Si naW <br /> Q 9 - Monts Day Year <br /> IY <br /> r <br /> T 18.Discrepancy <br /> .. _ - <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Patel Refection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facllity's Phone: <br /> W 18c.Signature ofAtemate 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 /> 1 H141 2. 9. 4. <br /> 1 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedRyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Fratricide Willi ps are obsolete. 4) DESIGNATED FACILITY TO GENERATOR <br /> 1 )0000839 1 <br />