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SK. SHIP# 2P5541717 Please Drinl or tvoe. (Form desioned for use on elite f12-nitchl tvoeweiter i IIIIIiIII IIIIIIIIIIIIIIIIIIIIIIIIIIII 006520E015KS Fnrm annm M MAP xln 9MA-MIG EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. IIt:'FO,- D fgIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) RECEIVED AUG 0 9 2018 ENVIRONMENTAL HEALTH DEPARTMENT UNIFORM HAZARDOUS 1, Generator ID Number T R'W0(7_tQ81 2. Pagpr��of 3. Emergency Response Phone 1 It . Manifest Track) Number 7006520801 WASTE MANIFEST X r_'05 /7( l/ , .. P V!0 F. � 1 7 f..0 0 0 6 5�L 0 8 01 SKS 5 Generators Name and Mailing Address Generator's Site Address (k different then mailing address) SAFETY-KLEEN SYSTEMS, INC. SAFETY-KLEEN SYSTEMS, IN, Fin BOX 555 5050 SALIDA BLVD :TDA CA 95368 09— ! 5- Generators Phone: 209--545-1011 sAt- I Dn 6 6. Transporter 1 Can ill" Nerne U.S. EPA ID Number SAFFTY KLFEN SYSTEMS INC 7. Transporter 2 Canpany Name U.S. EPA ID Number I -L -EAP; HARBORS ENVIRONMENTAL SVC INC. B. Designated Facility Name and Site Address THERMO FLUIDS INC U.S. EPA ID Number 1253.3 SE CARPENTER DR CI.ACKAMAS , OR 97015-89SR a._7Po_4616 OR00000c' Faau'sPhone ga 9o. U S. DOT Description (including Proper Shooing Name. Hazard Class, ID Number. t0. Contesters 11. Total 12. Unit HM and Packng Group IB any)) OuanUry Wlhbl. 13. yMaste Coda No. Type s NOM-RCRA HA7ARDOUS WASTE SOLID 0 w (r—'1,' -f "7rAINED 1.I5FD 61L. FII_TEPcS -- z z w 3 4 14 Special Handling Instruchom and Additional Information -c T r FPI(-F�FN17Yt 7 ,0 r17H Y / TFIi 15 GENERATORWFFEROR'S CERTIFICATION! I hereby declare Mall the contents of Bps Consignment are fully and accurately described above by the proper shipping name, and are classified. packaged, marked and laheied/placarded, and a-m all respects in proper condition for transport according to applicable intematioral and natronal governmental regulations. It export shipment and I am me Primary Exporter. I certify, that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenl of Consent. I certify that the waste minimization statement identified in 40 CFR 26227(x) (t I am a large quantity generator) or (b am a small quantity generator) is true. firs/Offeroe Ph yped Name signature A Year 16. In twnal Ipmeris ❑ Imp r rd U.S. ❑ Export nom U.S. on of exn try' ............................. .... ------------- ----- ding Z - Transporte ture (tor exports only): D U S.. 17 Transporter Acknrnvkdgment of Remo of Materials OTrir 1 Firm LTyped Sgnatu m Spy Year IZ 7-a stoner Punted; yped N Signature Month Day fear I 18 Discrepancy 18a. Discrepancy Indication Space ❑ Quentlly ❑Type ❑ Revtlue ❑Partial Rgectrorh ❑Full Rejection Mandest Reference Number J I Bo. Alternate Facility (or Generator) U.S. EPA lD Number U sal. FaaatysPhone �!2 w 1Bc. Signature of Alternate Facility for Generator) Morten Day Year a z y19 Hazardous Waste Report Management Method Codes (i e- codes for hazardous waste treatment. disposal, and recycling systems) U.1 0 H`�l 2 3 4. 20 Designated facility Owner or Operator Cemfi aton of recept of hazardous materiels covered by the manifest ex a n tem 8a l Prmled'Typed l>a(pe— SigriaNre Day Year ' `✓L z� ! x`.111 l NI `� O EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. IIt:'FO,- D fgIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) RECEIVED AUG 0 9 2018 ENVIRONMENTAL HEALTH DEPARTMENT