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'a <br /> FEB2'0' 200�yy+ <br /> Please print or type.(Form designed for use on elite(12-pitc0writer.) `• Form Approved.OMB Nq.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.M Re Tr c em er <br /> CAR000102707 X61 133 SKS <br /> WASTE MANIFEST 1 1-800-468-1760 <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than malting address) <br /> HOLZ RUBBER COMPANY INC. <br /> 1129 S SACRAMENTO ST <br /> LODI CA 95240 <br /> Generators Phone: 800-285-1600 <br /> 6.Tmnsder 1 Com n Nae U.S.EPA ID Number <br /> SAFETY-kLE1EI� SYSTEMS, INC. TXR000050930 <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 /> 916-386-4913 CA00000d4S17 <br /> Fedli 's Phone: <br /> ga 91b.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(if any)) No. Type Quantity WtNol. <br /> X1 WASTE PAINT RELATED MATERIAL, 3, UN1263, DMP FOO D00 DO1 <br /> o PG II, D035 D039 212 <br /> a4 <br /> z Z. <br /> W <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information SK TRCK#110315849 0038432921 0003153217 0907 24 <br /> 1)ERG;128 <br /> SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am fully and amrately 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 international 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 tens of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generators/00 is Pnntedrryped Name Signature Month Day Year <br /> G�.oif = lrsiv t � it Q <br /> 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Pod of entry/ex8: <br /> = Transporter signature(for exports only): Date Leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> K Trans PrnteMyped Nam Signature Month Day �Yee�ar <br /> O <br /> d //O"V GIC. O Z V/ <br /> QTra spoiler 2 Pni tedlTyped Name Signature Month Day Year <br /> ce <br /> t18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type a ❑Residue ❑Partial Rejection ElFull Rejection <br /> Ill Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> ria Facility's Phone: <br /> w 10c.Signature of A Remote Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> o L H141 2. 3. 4. <br /> 20,Designated Facility Owner or Opemtor.Certification of receipt of hazardous materials covered by the manifest except as rd in Item 18a <br /> Pin Na v Sign z nth Day Year <br /> F <br /> EP1A,F8$t1871 - ( elv.)3-05) Previous ediWareobsolete. 4) DESIGNATED FACILITY TO GENERATOR <br />