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7142 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Apbroved.OMB No.2050-0039 <br /> 1.Generator ID Number 2 Pae t of Errppergency Res�nsg p yn 4.Manliest Tracking Number <br /> UNIFORM HAZARDOUS CAR00'z1102707 4 —t'�i"... /:::�t1 t, 1003210923 SKS <br /> WASTE MANIFEST 1n� <br /> 5.Generator's Name and Mailing Address Generators Site Address(d different than mailing address) <br /> HOLZ RUBBER COMPANY INC„ <br /> 11P9 S ;'tacraffiento St <br /> Lod i CA 95240--' 7 l i <br /> Generators Phone: 800-P.815 '11600 <br /> 6.�rl Compa¢y-NaPIeSYS TFI%a' INCA U.S.EPA ID Number <br /> 7.Transporter 22 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS INC. Ii ID Number <br /> 172E COOPER CREEK ROME) <br /> DENTON, , TX 76208 <br /> 940--483•-Sr00 TXD07lfa03371 <br /> FBCllirys Phone: <br /> 98 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group If any)) No. Type Quantity WlNol. 13.Waste Cotles <br /> X 1'UNIMi WASTE METHYL_ ETHYL KETONE, � DM �� P DOW F00"PGI}, RQ(D001,F005) y) <br /> qQ OUTS, <br /> w X 'UN-3175 WASTE SOLIDS CONTAINING FL-AMMABI-r DM r, FIM liZell )035 <br /> LJOUID N.O.S. (METHYL FTFiYL KETONE, <br /> MTNERR., SPIRTTS)4. 1 PGII 352 CHM <br /> 3. <br /> as <br /> 4. <br /> 14,Special Handling Instructions and Additional Information SK 64113#206803286 57601408 31 3217 CSG; <br /> I Mitt''s t:7'€?ER&#133 <br /> 24 HR EM 66-468-1760 (SAFETY-'KLEEN - CONTRACT #94138) <br /> SK AUTH"D TO USE: S'UBSEGUENT CARP2IERS141078 41471 1681 82739 85399 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedere that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeted/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulators.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 certify that the waste minimization statement identified in 40 CFR 262.27(x)('d I am a large quantity generator)or(b)IN I am a small quantity,generator)is true. <br /> Generators/Offerors Pdntedrryped Name Sign�pre Month Day Year <br /> r 3 ; Z <br /> 161.International Shipments <br /> F ❑Import to U.S. ❑Even from U.S. Pon of entry/ex8: <br /> Transporter signature(for exports only). Dale leaving U.S.: <br /> ,may, 17.Transponerceipto/ <br /> AcknoWedgment of ReMaterials <br /> K Tanspor1 Printedi ad{4ame Signature Month Day Year <br /> W Transporter 2 Pnntedrryped Name Signature Month Day Year <br /> Q <br /> F <br /> 18.Discrepancy <br /> t 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Partial Rejection ❑Full Re' <br /> ❑Residue j Ikon <br /> Manifest Reference Number: <br /> 181b.Altemate Facility(or Generator) U.S.EPA I0 Number <br /> J <br /> U <br /> LL Facilitys Phone: <br /> uo 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> 0 <br /> N 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:CeNfiwtion of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> 1 PrintedRyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05LPrevious editions are obsolete. GENERATOR'S INITIAL COPY <br /> i- ,1,(1 1,A' 4)AttAs7 z r 11:1521 <br />