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7142 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Fon Approved. <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Eme ency Res onse Phone. 4.Ma ffest Tracking Number <br /> WASTE MANIFEST CALME57437 1 1-800-46�B-1760 0 3 3 2 9 6 5 5 <br /> 5.Generaces Name and Mailing Address Generators Site Address(g ddferem then mailing address) <br /> PARK AVE CLEANERS <br /> 2529 N TRACY BLVD <br /> TRACY CA 95376 <br /> Generators Ptwne: 209 914-1265 1 ' r'-' <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY-KLEEN SYSTEMS, INC. ( SAI TXR000050930 <br /> 7.Transporter 2 Company Name - U.S,&PAJO Number <br /> B.Designated Facill Name and She Address SAFETY-KLEEN SYSTEMS INC. UUH)Number <br /> 1722 COOPER CREEK ROAD <br /> Fackiys phone: 940-483-5200 <br /> , TX 76208 <br /> 940-483-5200 TXD077603371 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(H any)) No. Type Quantity yA,ryol, 13.Waste Codes <br /> X 1' RQ WASTE COMBUSTIBLE LIQUID N.O.S. P D0131 D007 D039 <br /> of (PETROLEUM NAPHTHA) NA1993 <�6III �,,�j� <br /> qa (D001) LJ" D040 7,41 OUTS <br /> w6991 <br /> z <br /> w <br /> C7 <br /> D040 751 OUTS <br /> 3. <br /> 6i i <br /> 4, <br /> 14,Spedai Handling Instructions and Additional lnfwmafion KSAIP#20097869AA1029243 3261950 201022 CSG:25 <br /> ll ERG#0128•R <br /> 24 HR EMER&ENCY # 800-468-1760(SAFETY-KLEEN - 94138) <br /> SK AUTH'D TO USE SUBSEQUENT CARRIER9:41078,41471,81681,82739.85399 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and acoumtely described above by the proper shipping name,and are classified,packaged _ <br /> marked and Izbeledlplacarded,and are in all respects in proper condition for transport acoDrdng to applicable international and national governmental regolations.If export slunment and I am the Pnmary <br /> Exporter,I certify that the contents of this consignment comform 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 quantity generator)or(b)(if I am a small quantity generator)is We. <br /> Gereratorstuffenors Pnnteary Nam//egra ra on Y ea <br /> 4`l S - L'?-lc <br /> S ` <br /> r16.International Shipments ❑Import to U.S. <br /> Z ❑Export from U.S. Port of emry/exr: <br /> Trinsporter signature for exports only): Date leaving U.S.: <br /> .w 17.TISIMPotierAcknoxkdgment ofRao*of Materiels <br /> Tran 1 Prmad7Typed Name St orey Year <br /> O <br /> a <br /> QZ <br /> lianspolial inmd/T am- igmonth <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ElQuantity ElType ElResiduePaft Rejection ❑Full Ral a. <br /> 1 <br /> Facility or Generator Manliest Reference Number. <br /> 18b.Alternate Fa <br /> tyl ) U.S.EPA ID Number <br /> J <br /> U <br /> LL <br /> Facility's Phws: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Reportanagement Method Codes(i.e.,codes for hazardous wasle treatment,disposal,and recycling systems) <br /> ED 1. 2. 3. 4. <br /> y 20. Facility e r peer Certification of receipt of hazardous matenals covered by the manifest e t a oted m Ite 16 <br /> ,- yped Name Signalur Month Da Yea`r <br /> L <br /> EP F rm 70 2 (Re .3-0 Pref iyu ed_tion§are gbsglete. D IG ATED FACILITY TO DESTINATION STATE IF REQUIRED% <br /> 1)256 i5M429 =n_-_ .- , <br />