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- I � , 1/ <br /> Please print or type.(Form designed for use on elite(12 pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDDUS 1.Generator ID Number 2.Pagel of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST I - •' <br /> 000283915 SKS <br /> 5,Generators Name and Mailing Address Generators Site Address(ff different than mailing address) <br /> LTEC BRAKE SYSTE.I'i- <br /> 174 POCK LANE <br /> ;T OCKTON C,A <br /> Generators Phone:209-9 8 2-1 m l b <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AFETY-KLEEN SYSTEMS, INC TxRC1'lt)J``'"3' <br /> 7.Transporter 2 Company Name US.EPA ID Number <br /> 8.Designated Facility Name and Site Address US ECOLOGY NEVADA 050505 U.S.EPA ID Number <br /> 11MILES S. HWY 95 <br /> ��' t1300i <br /> °05-559-2203 BEATTY fIST;f sfr%1 <br /> Faulitys Phone' <br /> gra 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(ffany)) No. Type Quantity Wt.lVd. <br /> ON RCRA HAZARDOUS WASTE LIQUIDS P ONE ' 22 <br /> or i OILY PIT SLUDGE AND WATER i <br /> z 2. <br /> w <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Information":k TRCK#108450621 0002074214 <br /> ii vpTATIJ r Tr ('4rVTFR- <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 labeled/placarded,and are in all respects in proper condition for transport according to applicable imemabonal 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 terms of the attached EPA Acknowledgment of Consent. <br /> I ceNly that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(HI am a small quantity generator)is true. <br /> Generatorst011 PrintedlTyped Name Signature Month Day Year <br /> .� 16.International Shipments <br /> r ❑Import to U.S. Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.'. <br /> W 17 Tmnspod6AcknoWedgmentof Receiptof Materials <br /> Transporter 1 PrintedrTyped Name Signature Month Day Year <br /> a C. ✓ - <br /> z Transporter Printed/Typed Name Signature Month Day Year <br /> rY <br /> r <br /> I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space [IQuanti <br /> tY ❑Type ❑Residue PaNal Rejection Full Rejection <br /> Manifest Reference Number: <br /> 181h.Allemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Ntemate Facility(or Generator) Month Day Year <br /> r <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4, <br /> 20.Designated Facility Owner or Operator:CeNficadon of receipt of hazardous materials covered by the manifest except as noted in Item IBe <br /> 111 Primedfryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> r;l p. ;, }..} GENERATOR S INITIAL COPY <br />