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7142 <br /> Please print Or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB Na.205n-(p39 <br /> UNIFORM HAZARDOUS 1.Generator lD Number CAL00021-437 2'F°ggl of 31Em91 WY Res000sepbonEO 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 GrJV 48tt d(B 004242312 FLE <br /> 5.Generetofs Name cunt MatLng Addre56 Generator's Site Address(if digerent Than mailing atldracs) <br /> PARK AVE CLEANERS <br /> 2529 N TRACY BLVD <br /> TRACY CA 95376 <br /> GeneraWs Phons. 209 914-1265 <br /> 8.T§As _ SYSTEMS, INC. U.S.EPA ID Number TXR000050934 <br /> 7.Transporter Company Nam U.S EFA Nu <br /> a� <br /> 6.Designated Facility Name and FeeAtldressAFETY—KLEEN SYSTEMS, INC. U.74 iD Number <br /> 1722 COOPER CREEK ROAD <br /> FacBiys Plrone: DENTON, TX 76208 <br /> 540-489-5200 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(dany)) No. Type Quanfily W1Woi. 13.Waste Codes <br /> X 1 RQ WASTE COMBUSTIBLE LIQUID,N. O. S. OF P D001 0007 D039 <br /> (PETRO(D001)LEUM NAPHTHA) NA1993 PGIII �0 D040 751 Di;TS <br /> z 2. <br /> u <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional lMgmetion SKS r 387 3261950 201119 CSG:25 <br /> 1)ERG#128; `� 6S <br /> 24 HR EMERGENCY # 800-468-1760( — — 94138) <br /> SK AUTH'D TO USE SUBSEQUENT CARRIERS: 41078, 41471, 81691,92739,85399 <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION; I hereby declare that the contents of Nis consignment are fully and accurately desaibed above by the proper shipping name,and are classified.Packaged, <br /> marked and Iabaled0laczNed,and are in all respects in proper condition for transport accoMing 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 terms of the attached EPAAGmowiedgment of Consent <br /> I oeNly that the waste minknizabon statement identifad in 40 CFR 252.27(a)(N I am a large quantity generator)a(b)(H I am a small quantity generator)is true. <br /> enerato erots PardedrTyped Name bignature Month Day Year <br /> V, lkskra' imp I Dp,- /`lir X"it- S 112,111 <br /> d 16.International Shipments <br /> i— ❑Import to U.S. ❑Expathi U.S. Pod ofentrylexit <br /> = <br /> Transporter signature for exports only): Date leaving U.S.: <br /> 17.TransporterAcknowkdgnnent of Receipt of Materials <br /> TranspWrier 1 Pdntedlfyped Name Signature month Day Year <br /> T2nspater dntedlf Name(' nature /} MonthDa� r, <br /> u if �f% 1y I til <br /> 18.Discrepancy <br /> l8a.Discrepancy IMicefion Space EJ Coal Coa ❑Type ❑Residue ❑Pzrtiai Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 186.Alternate Facility(or Gerarator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Fadi s Phare: <br /> w 18c.Signature ofAlterrate Facility(or Generator) Month Day Year <br /> zz <br /> 19.Hazardous Waste Ripon Management Method Codes(i.e.,codes for hazardous waste beatment,disposal,and recycling systems) <br /> O 1. 2. 3. 4, <br /> I <br /> 20.Designated F ty Owner or Operator.Cer6fica6 of ceipt of hazardous materials covered by the manfest rw in Item 18a <br /> Pnntedlf Signatur dwe <br /> EPt I g� 6Y `04-'ai Previous ed ons are obsolete. DESIGNATEb FA ILITY TO D ATION STATE(IF R 0 I ED <br />