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7142 "'I INII111111111111111111111111111{1111 <br /> 00�183p9313K5 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewrites) - ohim Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Menial:Tracking Number <br /> WASTE MANIFEST CAL000257437 1 1-800-468-1760 002830531 SKS <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than miming address) <br /> PARK AVE CLEANERS <br /> 2529 N TRACY BLVD <br /> TRACY CA 95376 <br /> Generators Phone: 209 914-1265 <br /> 6.Tra i Compo Name U.S.EPA ID Number <br /> SATY-KLEEEN SYSTEMS, INC. I TXR000050930 <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> CIN v- <br /> 8.Designated FadTty Name and Site Address SAFETY-KLEEN SYSTEMS INC. Ui4%D Number <br /> 1722 COOPER CREEK ROhD <br /> DENTON, , TX 76208 <br /> 940-483-520@ TXD077603371 <br /> FadTmys Phone: <br /> ga, 9b.U.S.DOT Des(tiption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Padang Group(d any)) No. Type Quantity Wt.Nol. <br /> cc X 1.RD WASTE COMBUSTIBLE LIQUID N.O.S. DF P DI D007 039 <br /> 0 (PETROLEUM NAPHTHA) NA1993 M1II <br /> D040 751 3UTS <br /> z 2. <br /> w <br /> 0 <br /> 3. <br /> 4. <br /> 14.Sped Handling llrsmndionsandAtbnal Information SK IP#2@4610266 4666064 3261950 201130 CSG:25 <br /> 1)ERG#128• <br /> 24 HR EMERGENCY # 800-468-1760( ETY-KLEEN 94138) <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dadam that the contents of this consignment are fuay and accurately <br /> descd above by the proper shipping name,ad are classified,packaged, <br /> marked and IabaleNplacsrded,and are in all respects in proper condition for transport according to applicable interns icreland national governmental 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large cuandty generator)or(b)(if I am a small quantity generator)is We. <br /> GenermMonth Day Year <br /> NTNN � 2?- <br /> I/ <br /> -jr 16.International Shipments <br /> j.. ❑Import to U.S. Export from U.S. Port of entry/exult <br /> E Transporter sigrature(lot exports only): Date leaving U.S: <br /> W 17.TrammorterAcknowledgment of Receipt of Materials <br /> tj Transporter 1 'ted(Typed Name Signature Month Day Year <br /> y (� 7 z2 y <br /> Q Trallisporter2 PrintedlTmOU Name Signature Month Day Year <br /> .\ �s <br /> r18.Discrepancy <br /> 18a.Disaepancy Indication Space El Quanlily ❑Type ❑Residue ❑Partial Rejection ❑FIJI Refection <br /> Manifest Reference Number. <br /> 18b.Aftemate Facility(a Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> w 18c.Signature of Affenate Facility(or Genen mr) Monti Day Year <br /> Q <br /> z <br /> y19.Hazardous Mq Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> t. 2. 3. 4. <br /> 20. gnatW Fad"Ny Owner art mr:Cem ileatlon of receipt of hazardous materials covered by the manifest except as road in hem 18a <br /> P n Name re V r <br /> EPA Fon 8700-22[Rev.3-05) Previou editions are ob tete. SIGNATEDFACILI DESTINATION STATE(IF REQUIRED) <br /> 1) 12569/1.,@424 <br />