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7-165-01 <br /> Please print or�pt-�€4a1914designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number T r 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Numper <br /> j �7 -1 27C, SKS <br /> WASTE MANIFEST +-,8C4-46�1--11s5© J'� "', •'+ .'. <br /> 5.Generators Name and Mailing Address Generator's Site Address('If d3terent than mailing address) <br /> TEMPLE INLAND <br /> 400 W VALP ICO RU <br /> TRACY CA 45376 9197 <br /> Generators Phone: 209-836-1971 <br /> U.S.EPA ID Number TXiR00fl050"0 <br /> �T�'��`� �"��r�T��s, Frac. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEJEN 'SYSTEMS INC. 400760+ U.S.EPA ID Number <br /> 6000 BOTH STREET <br /> SACRAMENTO CA 95826 <br /> x'16-386-4413 Ci OOOOO8431':- <br /> Facility's Phone: <br /> ga. 9b.U.S.DCT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.No€. <br /> 1NON—RCRA 14AZARDOUS t1ASTE, LIQUID 6 <br /> o (AQUEOUS PARTS WASHER SOLUTION) <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 14 Special Handling lnslruchons and Additonal Information S}( TRCK#110289160 0038381807 00003701OZ 0708 25 <br /> AUTHORIZED To RETAIN LICENSEE ".`'T CARRIERS AS NECESSARY <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATfON: I hereby declare that the contents of this consignment are fuliy and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national govennn i 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 EPAAcknowiedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or( f I am a small q tity generator)iS- e. <br /> G,enerato5,gitrors Pnntedrfyped Name Signature Month Day Year <br /> ox <br /> J 16.International Shipments <br /> F— ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials _ t <br /> T rintedlTyped Name Sign Month Day Year <br /> a <br /> ii <br /> ' �-.` /5 <br /> QTransporter 2 Printedlfyped Name Sig Day Year <br /> a <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity Type ❑ 1 ❑Full Rejection <br /> ❑ Residue Partial Rejection <br /> Manifest Reference Number: <br /> lab,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> II Facility's Phone: _ <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 4 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> a 2. 3. 4, <br /> 20.Designated Facility Owner or Operator:Certifica�t gn of receipt of hazardous materials covered by the manifest except as n in Item 18a <br /> PriMy t Signature Month Day YeAl <br /> P?g.��'�"'� ? {��v.3115} Previouse ti�nsareobsolete. �� DESIGNATED FACILITYTO GENERATOR <br />