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-.F: .i„ <br /> Please print or type.(Forra designed for use onelite(12-pitch)typewriter.) Form <br /> Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page i of 3.Emergency Response Phone 4.Manifest Trucking Number <br /> WASTE MANIFEST CAT000610949 �y G n rl n lI/+C�/ <br /> 11 5,Generator's Name and Mailing Address Generators Site Address(if different man mailing address) G G CA <br /> TEMPLE INLAND <br /> 400 W VALPICO RD <br /> TRACY CA 95376 9197 <br /> Generators Phone: 209-836-1971 <br /> 6.Transposer 1 Corti Name U.S.EPA ID Number <br /> SAFETY—KERN SYSTEMS, INC. TXROOOOS0930 <br /> 7.Transporter 2 Company Name _ U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, INC. 000760 U.S.EPA ID Number <br /> 6000 BOTH STREET <br /> SACRAMENTO CA 95826 <br /> Fadlilys Phone: 916-386-4913 CAOOOOO84517 <br /> gi 9b.U.S.DOT Desorption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(If any)) <br /> No. Type Quantity WLNoI. <br /> 'NON—RCRA HAZARDOUS WASTE, LIQUID CM 134 <br /> o <br /> (AQUEOUS PARTS WASHER SOLUTION) <br /> R Y� <br /> w <br /> z 2. <br /> w <br /> I- <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information SK TRCKM110932245 0039962705 0000370102 0942 25 <br /> Sk AUTHORIZEDD SUH <br /> 15. GENERATOWSIOFFEROR'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 /> marked 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 EPA Acknowledgment of Consent. <br /> I cedlfy that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generetors/Offemrs PnntedfTyped Name Signature '1 Month Day Year <br /> F <br /> 16.International Shipments ❑Import to U.S. ❑Export from U.S. Portof entry/exit <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> C Trans oder 1 Printedfiyped Name r 5192 Month Day Year <br /> 0 E- c L/ <br /> z Transporter Pdnted/fyped Name alum + Mbn Da7 Year' <br /> K <br /> f <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Qcenfi T <br /> ry ❑ type ❑Residue ❑Perttel Rejection Ll Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 19.I-Immous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> I H141 z. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnnted(Typed Name Signature Month Day Year <br /> gP�� 887x40,22(Rev.3-051Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />