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1�! Pleas,print or type.(Form designed for use on elite(12-pit writer.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number r F0102707 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number _SKS e <br /> WASTE MANIFEST CARS 1-500'469-'1760 001915831 V„V <br /> 5.Generators Name and Mailing Address �I' ,) Generators SiteAddress(if different than mailing address) <br /> HULZ RUBBER COPPI IMC. <br /> 1127 S SACRAMENTO ST <br /> L D D I CA 95240 <br /> Generators Phone: 800-285-1600 <br /> U.S.EPA ID Number <br /> s ` f"` raY5TEM5, INC. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address SAFETY-KLEEN. SYSTEMS, INC. 0{)0760 U.S.EPA ID Number <br /> 6000 88TH STREET" <br /> SACRAMENTO CA 95828 <br /> 916-386-4913 <br /> Facility's Phone: <br /> ga 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(if any)) No. Type., Quantity Wt.Nol. <br /> X 'WASTE PAINT RELATED MATERIAL,3, UN1263, Dn P r008 cf;C' ?_• <br /> P0 PC II, ! J035 D213;' <br /> z 2 <br /> W <br /> rm <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 5K TRCK11110-328092 0038940573 0003153217 0920 34 <br /> 1)ERta€i12S <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 respea s 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 idendfied in 40 Cl 262.27(a)(8I am a large quantity generator)or(b)(if I am a small quantity generator)is we. <br /> Generetoes/Ogerors Printed7Typed Name Signature -- Month Day Year <br /> —, 16.International Shipments rt from U S pod of en R: <br /> F- El Import to U.S ❑Expo MIex <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.TrensporterAcknowiedgment of Receipt of Materials - <br /> Transporter l Printed/Typed Name. J -- - Signature 1•c. -— Month Day Year <br /> t � <br /> M Transporter 2 Pdntedflyped Name. - - Signature - Month Day Year <br /> Q <br /> C <br /> H <br /> 18.Discrel <br /> 18a.Discrepancy Indication Space ❑ Quantity -❑Type1-1j ElFullRejection <br /> ❑Residue Partial Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> 7 <br /> V <br /> LL Facility's Phone: <br /> w 18c.Signature ofAtemate Facility(or Generatorl. Month Day Year <br /> a <br /> y19. o a poRM - nV6�etirod Codes(i.e.,codes fqrrolKwaste tre ent d - and r g " <br /> 0. c 2 3, 4. <br /> IIe41 <br /> 20.Designated Facility Owner or Operetoc CeN6cadon of receipt of hazardous materials covered by the manifest except as mod In Item Ise <br /> Printedrryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> 10012607 2) 3) 4) <br />