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1St • .T <br /> Frease 'int or type,(Form designed for use on elite(12-pitch)typewriter.) Form Apprnvsd.DMS No,2050-0039 <br /> UNIFORM HAZARDOUS 1.GensralorW Number 2.Page'1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST � 00(1 ` 16- 290 <br /> 5.Generators Name and MailingAddress Generaloes SuAidto%(if different than mailing address) <br /> CXIP 95213i <br /> Gerrerehar`sPhone; <br /> 8,Transporter 1 Company Name U.S.EPAID Number <br /> INC- <br /> 7.Transporter 2 Company Name U.S.EPAID Number <br /> 8.Designated Facility Name and Site Address Sif3)'ET,)'—KLEFN SYST.'V S, INC. 000760 U.S.EPA ID Number <br /> 6000SBT14 STPLET <br /> SACRAMEN7r) CA 9,5$25 <br /> Facility's Phone: <br /> 9a, 96.U.S.DOT Description(nduding Proper Shipping Name,H3;Wd Class,ID Number, 1O.Containers 11.TOW 12.Unit 12.Waste Codes <br /> HM and PaCf6ng Group(4 any)) Na, Type QvanVty Wt.lVoi. <br /> tt ) u�iC:Fi�`i H�t'IARDBUS 1 ,4,Tf d LIQL1.,`4u ON 1 v NONE ,1311 <br /> (AGUEMS PAS,JS WASHER SOLUTION) <br /> 2. <br /> w <br /> a, <br /> 4. <br /> 14.Special Handing lnsbuctionsand Additional Information k -TRC'b{N1Q6-4241$6 .00-.M.114914 0000VILMO 0'?Z1 <br /> a ;* t {` f' -t. <br /> r° <br /> 15. GEN ERATOR'SIOFFERDR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shlpyfng name,and are dassilied,padcaged, <br /> markod and fabel6d)`009rded,and are in all respects In propermndtlon for transport a=fding to applicable international and national goven mentar regulations.If export shipment and I am the Primary <br /> Exporter,I oer*that the contents of ibis Consignment conform to the terms of the attached EPAAckworledgmernt of Consent <br /> I certify that the waste mtnimization statement ident6ed in 40 CFR 262,27(a)(if I am a large quantity generator)or(b)(if I am a small quantity piaretor)is true. <br /> GeneraloesJOfferoes PrfntedrTyped tame Signatu f Month Day Year <br /> ?�,. w d C� L A 'Q rriF � T 1 (Fj' y f✓1 . '�_ Y <br /> F 16.tnlernalIonel Shipments ❑Import to U,S. ❑Export from U.S. Pori of enUylaxit:` <br /> Transporter signature(tar exports only). Date leaving U.S.: <br /> 17.Transporter Ackrlonvledgment of 11600 of Mated& <br /> LLI <br /> Trenspo PrinledfrypedName Sigg3lure 6 j Month oay Year <br /> Transporter 2 PrinIM yped Noma Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ ,Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alleniale Facility(or Generator) U.S.EPA ID Nurnbar <br /> Facility's Phorvw <br /> w 18c.Signature of Alternate Fadi ty{or Generator) Month Day Year <br /> �—� 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,d1posaf,and recycling systema) <br /> 1. 2, E <br /> 4. <br /> 20.De%ignaled Fadllty Owner or Operator:CienTicalion of receipt of hazardous materials covered by the manifest except as n jgd in Item 1 Be <br /> Mouth Day Year <br /> r r <br /> EPA Foh 8700-221Rev.3.051 Prevlousedition&arechsn P. �ivit i-nrarerirnru rSVTrti f` Ar�nwrnn nz-•rr.,�n�n,rrn ... <br /> 899-3 TZO/GTE OGZ-L SZ :ZL OT,-81-Ta <br />