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7-185,,>01 ` <br /> ,r <br /> Please pdnt,or typ.(Form designed for use on elite(12-pitc writer.) 0. <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.ManifestTracking Number y�+ <br /> WASTE MANIFEST CAR000I02707 1 1-800-468-1760 002079081 SKS <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> HOLZ RUBBER COMPANY INC. <br /> 1129 S SACRAMENTO ST <br /> LODI CA 95240 <br /> Generators Phone: 800-283-1600 <br /> 19MVERWSYSTEMS, INC. U.S.EPA ID Number TXR040030930 <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 93828 <br /> 916-386-4913 CA00CJOS4517 <br /> Faciliys Phone: <br /> gy 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number 10.Containers 11,Total 12.Unit <br /> HM and Packing Group(it any)) 13.Waste Codes <br /> No. Type Quantity Wt./Vol. <br /> X 'WASTE PAINT RELATED MATERIAL,3, UN1263, DM P FO0 0001 0018 <br /> CC PG II, ` 6 003 0039 212 <br /> z Z. <br /> w <br /> C7 <br /> 3. <br /> i <br /> 4. <br /> 14,Special Handling Instructions and Additional Information SK TRCKM110732038 0039487650 0003133217 0932 24 <br /> 1)ER08128 <br /> SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 15: GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment ere 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 con Lbgn 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 terms of the attached EPAAcknawledgmant of I. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)Con a small quantity generator)is We. <br /> Generators/OBemes Printed(Typed Ne a - I Signature_ Monyi_. Day Yea <br /> 16.InmilrationalWments <br /> {— ❑Import to U.S. ❑Expod fro - Pon of entry/exit <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> W17.TrensporterAcknowledgment of Receipt of Materials <br /> Transporter 1 PrintedlTyped Ne Signature Mont _ On Year,( <br /> N C� <br /> 4 Transporter 2 Pnntedrfyped Name Signature Month Day Year <br /> K <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity 1:1Type ElResidue ❑Partial Rejection ❑Fun Rejection <br /> Mandest Reference Number. <br /> 181a.ARemate Facility for Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Facility's Phone: <br /> N� 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. H141 2. 3. 4. <br /> 120.Designated Facik or Operator:CeNficatio ipt of hazardous materials covered by Me manifest except as noted in Item 18a <br /> Prinled/fyped Na Signature Month Day Year, <br /> ( D� <br /> EPA Form 87OO-22(Rev.3-O5) Previousedi sareobsolete. DESIGNATED FACILITY TO GENERATOR <br /> 1)0012607 2) 3) 4) <br />