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' i-185—f)i <br /> P <br /> Please print or type.(Form designed for use on elite(12-pitcwriter.) 40 <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS i.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CARD00302707 1-800-468-17,60 1000393172 $K$ <br /> 5.Generators Name and Mailing Address Generators$ilg Qddup,L(different <br /> V E D testing address) <br /> HOLZ RURRER COMPANY IMC. �(t t <br /> 1129 S SACRAMENTO ST <br /> LODI CA 95240 JAN 2 2 2009 <br /> Generdors Phone: 600-285-1600 <br /> 6.TraT�oder 1 Company Name U.S.EPA ID Number <br /> SAFETY—VLEE14 SYSTEMS, INC, TXR000050730 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, INC. 000760 U.S.EPA ID Number <br /> 6000 88TH STREET <br /> SACRAMENTO CA 95828 <br /> Facllitys Phone: 916-386-4913 CAOOOOO84517 <br /> ga 91b.U.S.DOT Desorption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No, Type Quantity WINol. 13.Waste Codes <br /> X �JASTE PRINT RELATED MATERIAL,3, UN1263, OM P F003 D001 0018 <br /> R PG IT, <br /> qa s D035 D039 212 <br /> z Z. <br /> W <br /> (7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information SK TRCK#110153884 0038023234 0003133217 0901 24 <br /> 1)ER8k12R <br /> !%IFCFSSA.RY <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for henspon according to applicable international and national governmental regulations.It export shipment and I am the Primary <br /> Exporter,I unity that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quanfity generator)or(b)(it I am a small quantity generator)is We. <br /> Generators/Offemes Primed/Typed Name Signature / Month Day Year <br /> -ai 16.International Shipments <br /> F- ❑Import to U.S. ❑Boon from U.S. Pod of enhylexa: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> ¢ Transporter 1 Printetl/Typed Nam - Sign Month Day Year <br /> g RR}H <br /> a Transporter-2Pnntedffyped Name Signature Month Day Year <br /> C <br /> 1-- <br /> t18.Discrepancy <br /> 18a.Discrepancy Indication Space- ElOuantity ❑Type 11Residue ❑Par6a1 Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facilitys Phone: <br /> w iBc.Signature ofAltemate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C3 1 H141 z. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as n5ed in Item 18a <br /> P.ddedll ed ante -� SignaWre Monty Day Year <br /> a• <br /> EPA F 700-22(Rev.3-05) Previous e I onsareobs lete. DESIGNATED FACILITYTO G NERA R <br /> 1)0012607 2) 3) 4) <br />