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7142 `, _ IIIIIIi��Cfll <br /> ooxosx <br /> Please print or type.(Form designed for use on"(12.0tch)typewriter. Form Approvetl OM8'ryp. <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Pegs 1 of 3.Eme ency R Phone d,Manliest Tracking Number <br /> WASTE MANIF CRL0a02s7437 1 i.-81`10-48 1760 0 0 2 9 5 2 9 5 6 S <br /> 5.Gereratol's Name and Mailing Address Generatofs Site Address(d adferent Than marling address) <br /> PARK AVE CLEANERS - <br /> 2529 N TRACY BLVD <br /> TRACY CR 95376 <br /> Generalofs Phone: 209 914-1265 <br /> U.S:EPAID Number <br /> s.TSq Y mt�O SYSTEMS, INC. TXRaa0050930 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number p p(y'�p <br /> O 1.0� JOO { 1 ' <br /> 8.Designated Facility Name and Site Address; SAFETY-KLEEN SYSTEMS INC. U:�.��DNumber <br /> 1722 COOPER CREEK. ROAD <br /> DENTON, TX 76208 <br /> 94a-483-5200 TXD077603371 <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description on ludkg Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codas <br /> HM and Packing Crwp CA any)) No. Type Quantity VJ <br /> X 1, NA1993 RQ WASTE COMBUSTIBLE LIQUID, �l <br /> (Da01) � P D001 D007 D039 <br /> o N.O.S. (PETROLEUM NAPHTHA) PGIII S DOW 751 OUTS <br /> pia <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Spedal Handling Instructions and Additional Information SK SHP#206062655 6902792 3261950 20121 CSG:25 <br /> 1)ERG#1r^_8' <br /> 24 HR EMEAGENCY # 800-468-1760(SA TY-KL - 94138) <br /> SK A 1 F S. <br /> 15. GENERATOR' - FEROR'S CERTIFICATION: i hereby declare tltal the=lards of this consignment are fully and accuri described shove by the proper shipping name,and are caballed,packaged, <br /> marked and'Iabeleciplecarded,and are in all respects in proper mnditien for transport acwrding to applicabla International and national gm emmanal regulations.If export shipment and 1 am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknoMedgment of Consent <br /> I certify that the wade minimization statement identified in 40 CFR 26227(a)(If I am a large quantity generator)or(b)(fl am a small quantity,generator)is true. <br /> Gen arslOferods Printedrryped Name Signature Month Day Year <br /> K FJ 1 <br /> J 16.Intematlonal f�Shipments <br /> H ❑Import to u.S. ❑Export from U.S. Pon of entrylexh: <br /> = Transporter signature(for exports only): Date leaving U.S.' - <br /> w 17.TransponerAcknowledgmeMd Recegt of Materials <br /> Tmnqbdw 1 Printed/Typed Name Signature Montle Day Year <br /> QTransporter 2 NnIfflYptoniarre Signature `/ Month Day Year <br /> Z2 z1W <br /> i <br /> j18.Dacrepancy _ <br /> 18a.Disoepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Pardee Rejection ❑FUJI Rejecrian <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> I< Factiitys Plane: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> N19.Hazardous Waste Report Management Method Codas(i.e.,codes for hazardous wase treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 20.Designated Facility 6wre,or Cpemtor.Certification of receipt of hazardous materials covered by the manifest t as rested in Item 18a <br /> Ndnwypw Name Sig Month. ay Year <br /> EPA)Fgp4700-22(e.�) Previouseftonsare obsolete. D IGNATED FAC LI YTO DESTINATION ATE(IFREQUIRED <br />