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-' SK MIP# 223069802 0 0 6 1 3 6 9 5 9 S K 3 <br /> 1'lua3e print yr :(forrri desi tied for use on elite(12-pitch)typewriter.) <br /> Form Approved.OMB No.2050-0035 <br /> DO 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4•Manifest Tracking Number <br /> llNiFORM CAL000397036 1 1-800-468-1760 O O f 13 6 9 8 9 SKS <br /> WA E MAMFEST <br /> :,.Generators Name and ti7Ji1ng Address Generators Site Address(if di"erent than mailing address) <br /> Foodliner Foodliner <br /> PO BOX 55293 2467 E Mariposa Rd <br /> STOCKTON CA 95205-7893 <br /> Generators Phone 209-648-5020 STOCKTON CA 95205-7893 <br /> 6 Transporter 1 Company Name V.S.EPA IO Numher <br /> SAFETY—KLEEN SYSTEMS INC I TXROOM81205 <br /> 7.Tr-rsporer 2 Canoany Name U S EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> ,.i g..Designalad Faulity Name and Sre Address CLEAN HARBQRS OF WILMINGTON LLC U.S EPA ID Number <br /> 1737 EAST DENNI STREET <br /> WILMINGTON , CA 90744 <br /> CAD044429835 <br /> 310-835-9998 <br /> FBciiity's Phone: <br /> 6a 0b.U.S.DO'.Description(including Proper Shipping Name,Hazam Class,ID Number, 10.Contaners 11.Total 12,Unit 13.Waste Codes <br /> 14M aNPack:ngGroup(dany)) No. Type Quantity WtNol. <br /> al 1 NOt —RCRA HAZARDOUS WASTE, SOLID ! DM '�� P <br /> (OIL FILTERS) ` <br /> W <br /> �LJ <br /> 2. <br /> ) <br /> 14.Speual Hsndling Instructions and Aodifio'ial Information TSD 7 WI 741E 10232 F021051 CSG: <br /> 24 HR EMERGENCY #1-800-468-1760' (SK ! TF I) 176 , <br /> S GENERATOR'S EROR'S T1FIC Oy de <br /> N: I mbclare that the contents o t is conslgrmrenl are linty and accurst described above by the proper shipping na—mee,,and are classified,packaged, <br /> marked and labeledpiacarded,and are in all respects in proper condition for transport according to applicable ntemational 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 toms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste mirumizaton statement identified in 40 CFR 262.27(a)(d I am a large quanrry generator)or(b)(of I am t quantity generator)Is true. <br /> Generator'srOflemes Printed/Typed NameSignature Month Day Year <br /> J2nhe1� <br /> 16.Internalional Shipment; <br /> �- ❑import to U.S. ❑Export from U.S. PM of entrylexic <br /> Transporter sigmalue(fo•exports onlyi: Date leaving U.S.: <br /> iu 17,TransponerAcknoWedgment of Receipt of Materals <br /> tC Tran r 1 Printedrryped a Signature Month Day Year <br /> tL ` .rte �� 17 <br /> [L <br /> -r Trans ort Pri /Typed Name Signal Month Day Year <br /> yz <br /> 18 Discrepancy <br /> 18a Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Ful Rejection <br /> Manifest Reference Number: <br /> 48b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> C3 <br /> L Faabty'sPhone <br /> L J 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 79 Naza Qpm Waste Report Management,MettiorJ Codes(i.e.,codes for hazardous waste treatment,disposal,and rung systems) <br /> R� 1. I .. <br /> l2.el <br /> 20.Cesrgnated FaOayOwner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pr rated Type Mame Signature Month a Year <br /> t`AF0r 8700-22{Rev� S)Frevousedtivnsare te, DESIGNATED F CILITYTO DESTINATION STATE(IF REQUIRED) <br /> 31155777 <br /> afkt f <br />