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x0101"08/2009 13. 47.7 2095453680 SAFETY—KLEEN PAGE 01%01 <br /> ■■■■■ <br /> ■ ■ <br /> ■ pleAse print or type,(Form designed for use an elite 12•pftoh)typewriter, Form Approved.OMI6 No,20800039 <br /> UNiFORM'fiAZARDOUS 1.Generator ID Numbar 5` 3 7 r7q p 2.Pqe l of 3.Emergency Response Phone a.r anlfast Trsaking Number <br /> SKS <br /> WASTE MANIFEST �;^ .$drf�� :r � q.X,._. '�l l� <br /> 5.Go @ralQ�a oma a,Cd 1a In Add111 generator's SitoAddroe:<(If different than mailing address) <br /> k,1't d. gC;9k1T ' �ti' Pt dad <br /> t}enefetor'a Phone: 4(f'T'•-T,Af 4--5-V21 I <br /> 6iti��6p°rtlor l,G� PL Nf m `.`i T t'(, r t+14, U.S.EPA ID Number T f�'k7O S q 5",311 <br /> 7.Tranaporler 2 Company Name U.S.I;PA ID Number <br /> 8,designated Faclilty Name end Site Address 'F e Y'•_a �E ;�f a 14 k J)+; r;r �y? U.S.EPA ID Number <br /> Y;40 FOTH STREET <br /> Factit s Phone: <br /> 4a. 45,U.S,DOT Deacrlpllan(including Proper Shipping Namo,H171rd Class,iD Number, 10.Containers 11:Totsl 12.Unit <br /> NM and Packing Greup(If any)) No. Tyne 4uanthy Wt,Nol; 13,waste Codes <br /> Q r{ACIUO];JS PARTS. VASHf:.R Sw-P U T ION) p � <br /> r— <br /> z 2. <br /> U_r <br /> CD <br /> 3: <br /> d. <br /> 1ti.Special Hartdiinglnetruedonsand Addllioneflnfortnaon :.'Ji1, tr,,, ,�'y' is} ddb. r Q5 r6U4voP L"ra,3yl. 7 1,71;14 Out <br /> Sig V1 N'r�.TATN t..1CM4Sf 2 Li aa: Lt f• 't' .. � 'F�.r, Ffi d�} ty ��i't' <br /> 15, GENERATOR'SIOFFF.ROR'S CERTIFICATION:.I hereby dociaro Ihat iho conwnls or this canslgnmont aro fully dnd accurolely daccrlbed above by the proper shipping name,and ate closet Nil,packaged, <br /> merhed end lebeiadlplacarded,and are in 611 respects in pmpor condillon for lranspon according to appllcabla iritomatlonol and nallonal govommontal reguiatlona,If export cihIpment artd I am The Primary' <br /> Exponor,I cortify that the Contents of this consignment conlorm to Ilfe terms of the ettsched EPAAcknewlP.dgmant of Consent. <br /> I certify that the wasta minimlzatlon slal*ment IdentlF*d In 40 CFR 262.27(a)(If I am a large quanilty generator)or(b){if I am a smoll quinety gonorator)Is Iruo <br /> Den arstoes,%Yleror's Ptintedlf yoed Name I Signature Y Month Day Year <br /> ."! 16.Intemeticnel 9htpmanka. Export from U.S, Port of entrylexll: <br /> ❑ <br /> �_— ❑Import to U.S.Trunaportnr sign-,#vm(ror exports only)! Dnto loaving U.S.: <br /> 17,TransporterAftowledgmem of Receipt of Matel9als <br /> re Tronsport*1r)Pr)tt dirryp*d Name Signatures �,.� ' !�1 Y.Day Month R <br /> r ar <br /> aTMnsptherg PrintidrrypadName 3lgnerura Month . Day Yoar <br /> K <br /> 18.DlRcrepancy <br /> 161,Discrepancy Indfcatlen Spece ❑ Ovantft Y Dryp' ResiduPgrfll Releolan ❑Full ReJecson <br /> t Reference Number: <br /> 18b.Altamato Paeility(or Gancrafor) Manff*a . U.&-EPA ID Number <br /> C7 , <br /> L FRCIIity'a Phone: <br /> 1bc.Signature ofAlromart;sac l ty(or 'nnoralor) plarM Day Yesr <br /> 1 q.Hazardous+>'laslB RepOfl MAilagamant Method Codas(r.*.,coffee for hs7ardotfs%vast*treatment,d1spo9al,and rncycling systoms) <br /> 2. <br /> 20,Deal®natnd FncllitY Owner ar Oposabr.G'ailflc*tlor of recelpt of hazardousmatertala covomd by lho manliest exceo as rued In hem lea <br /> Primop;ypad Nam* SignatureNIonlh Day Year <br /> apP� -3�� 2(Ref.3.05) Previous*dltlond are obsolete. .a TRANSPORTEFI•S COPY^ <br />