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Please print or type.(Form designed for use on ebs,,ft-'}JI[Eh)typewriter, <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAT000610949 1 2.Page 1 of 3,Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 808-468-1760 002184213 SKS <br /> 5.�pWF nfffld HPMog Address - Generator's Site Address(Ndigemnt than mailing address) <br /> 400 W VALPICO RD <br /> TRACY CA 95376 9197 <br /> '09 836-1977 <br /> Generatots Phone: <br /> 6-qW,'e"Er"te$inaSYSTEMS, INC. U.S.EPA ID Number TXR000650 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address JF*t:I T—KLEEN ST 1EMS, INC. INN 7 GO U.S.EPA ID Number <br /> 6000 BOTH STREET <br /> 916-386-4913 <br /> SACRAMENTO CA 95829 <br /> CAIafD00084:;1 <br /> Facili 's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Padding Group(if any)) 13.Waste Codes <br /> _RCRA No. Type QuantityWtNol. <br /> tiH I'M <br /> 0 (AQUEOUS PARTE Wd1SHER SO UTION) ` /� a <br /> `1 l/ <br /> w <br /> z z. <br /> W <br /> 0 <br /> 3. <br /> 4. <br /> i,f pedal Handling Instructions and Additional Information •� _ <br /> 24 HR EMERGENCY # 800-468-1760(SAFETY-KLEEN - 94138) <br /> SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> readied and labeled/placarded,and are in all respects in proper condition for transport according 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 EPAAcknowledgment of Consent. <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or("I am a sm antity qe r)is true. <br /> Ge s/Olom atetllT d Te .� Si nature MpgW, Day Year <br /> L 3 <br /> 1 (91 <br /> tib.Internalafral Shipments <br /> F ❑Import to U.S. Ll Export from U.S. Port of entry/ it: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> K Tmnreqr 1 Pnntecffyped Na Sgn i M N Day Year <br /> a [ J <br /> N L <br /> Q Transporler2PdntedRyped Na SgnaNre Month Day Year <br /> f <br /> ♦ 18.Discrepancy <br /> Its.Discrepancy Indication Space <br /> ❑ Quantity El Type ❑Residue Ll Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18D.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Fadllty'a Phone: <br /> w 18c.Signature otAltemate Facility(or Generator) Month Day Year <br /> z2 <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> uJ 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Cerfification of receipt of hazardous materials covered by the manifest except aso ,m Item Ise <br /> PdrNamg� Signature Month Day ,-Year <br /> Ef90@qeJ@WJ(Fts�3-05) Previous editlops are obsolete. 4) DESIGNATED FACILITY TO GENERATOR <br />