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SSL '`' SK SHIP# 22KA6394 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.21 <br /> UNIFORM HAZARDOUS t.Generator ID Number 2 Page I o` 3.f Response Phone t nc g bar <br /> WASTE MANIFEST CALOM97036 1—$ --468-1760 705523,393 SKS <br /> 5.Generator's Name and Mailing Address Generators Ste Address(If different then mailing address) <br /> Foodliner <br /> 2467 E Mariposa Rd <br /> STOCKTON CA 95285-7893 <br /> Generator's Phone 209-642-5020 <br /> 6.Tr Wrier 1 CompanYName U.S.EPA ID Number <br /> SAFETY—KIEEN SYSTEMS, INC. TXR880881285 1 <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> s <br /> 6.Designated Factltty Name and Site Address CLEAN HARBORS OF WILMINGTON LLC .EPA ID Number <br /> 1737 EAST DENNI STREET <br /> FacAlt's Phone: WILMINGTON , CA 90744 <br /> 318-835-9998 CAD044429835 <br /> 9a 96.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11.Total 12.Unit <br /> HM and Packing Group(if arty)) No. Type Quantity W1,1vol. 13.Waste Codes <br /> Or1 NON—RCRA HAZARDOUS WASTE, SOLID DM P 223 <br /> 0 (OIL FILTERS) - <br /> W <br /> W 2 <br /> (7 <br /> 3. <br /> 4. <br /> I <br /> I <br /> 14,Special Handling Instructions and AdNtonal Information TSD t W I 71801358 F021051 CSFs 4 <br /> lac �x�e.kJJki <br /> 24 HR EMERGENCY •1-880-458-1768 (3K / TFI) <br /> n u <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 labaledlplacardad.and are in all respects In proper condition for transport according to applicable international and nallonel gover mental 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 cerfify that the wasae minimization statement identified in 40 CFR 262.27(x)(if I em a large quantlry,generator)or(b)(f 1 am a small quantity generator)is true. <br /> GeneratorslOHeror's Printed/Typed me Signature Month Day Year <br /> PS✓S 1 r' U—v o 6 116 <br /> .-r 16.International Shipments <br /> Z ❑Import to U.S. ElExpert from U . Port of entry/exit <br /> TranspVer signature(for exports only): Date leevng U.S.: <br /> W 17.Transporter Admowledynenl of Receipt of Materials <br /> OTransporter 1 Printedriyped Name Signature Month Day Year <br /> 4 spo ler rrledlTYped ren ure Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.AMemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rQi Fackity's Phone: <br /> Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> y19.HazardousWaste Report Management Method Codes(i e..codes for hazardous waste trastment,disposal,and ncycing systems) <br /> LLJ p 1 <br /> ,I11q' 2 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the merits I except as Hued in item 18a <br /> PrimedrType Name th ear <br /> ��+� � ) I <br /> EPA Form 8700-22(Rev.3-05 Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> 1)7612003/156777 <br />