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print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 <br /> iNIFORM HAZARDOUS 1,Generator ID Number CAT000610749 2.Page 1 of3.Emergency Response Phone 4.Manlie(st�Trrpeking Number SKS WASTE MANIFEST 1 1-800-468-1760 0 Q L 071322 SKS <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> TEMPLE i E) <br /> 400 W VA.- ?;O RD <br /> TRACY CA 95376 9197 <br /> Generators Phone: 209-836-1471 <br /> U.S.EPAID Number <br /> s.Irgn�lar�1 Cpllpypy-l9am 5Y5TEi15. FNC. TXR000O50430 <br /> 7.S TraansspoortTerT2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN SYMMS, INC. 000760 U.S.EPA ID Number <br /> 6000 BOTH STREET <br /> SACRAMENTO CA 45825 <br /> 916-386-4913CAOOOOO64517 <br /> Fackitys Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, A 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Paddng Group(l any)) No, Type Quantity WI.Nol. <br /> NON—RCRA HAZARDOUS WASTE DM 0 34 <br /> 0 (AQUEOUS PARTS WASHER SOi_: <br /> � . <br /> w <br /> Z 2 / <br /> Ulu <br /> , <br /> co i <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional ImommitongH7SED <br /> #11O715465 0039416150 0000370102 093E <br /> TNORiZEO TO RETAIN LIC SUBSEQUENT CARRIERS AS NECESSARY <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby d[ are that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged. <br /> marked and labeledlplacarded,and are in all respects in pryyer condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cedify that the contents of this consignment co min to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified m 40 CFR 262.27(a)if I am a large quantity generator)or(b) I am a small qua generator)is we. <br /> G eratoesl erors Pdntedrryped Name Sig Wre Month Day Year <br /> rre� <br /> .International Shipments <br /> ❑Import to U.S. ❑Expwt from U.S. Port of entrylexa: <br /> ansporter signature(for exports only): Date leaving U.S.: <br /> Transporter Acknowledgment of Receipt of Materials <br /> otter 1 PrintedRyped Nam re Month Day Year <br /> n sc -, L- 1 - I -) <br /> wrier 2 PrintedlTyped Name nature Month Day Year <br /> agency <br /> epancy Indication Space ❑ Quantity• ❑Type ❑Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> Manimst Reference Number. <br /> P Facility(or Generator) U.S.EPA ID Number <br /> t <br /> me: <br /> Fie of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> co I s Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> Facility er or Operator.Certification of re of hazardous materials covered by the manifest except as noted in Item 18a <br /> d Name Signature Month Day Year <br /> //�d <br /> F ✓ t —j Z Z, CS 7 <br /> -22(Rev.3-05) Previou eclMon reobsolete. � N; <br /> t9NATED FACILITYTO GENERATOR <br /> 5) 4, <br />