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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> f umber Form Approved.OMB Na.2050-0039 <br /> UNIFORM HAZARDOUS 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST '"'`- - �� <br /> 5.Generators Name and Mailing ` ` {� '^ ? <br /> Generators Site Address(if different than mailing address) <br /> TEMPLE iNLAW)U <br /> 400 W VALPICO TQA�..7 �`L,Generators Ph one: t+9-8 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY-KLEEN SYSTEMS, INC. TXR00005093R <br /> ffPhone: 9 <br /> amper"Name U.S.EPA ID Number <br /> lity Name and Site Address U.S.EPA ID Number <br /> SAFETY-KLEEN SYSTEMS, INC. 000760 <br /> 6000 88TH STREET <br /> SACRAMENTO CA 95828 <br /> 916- 386-4913 CA000OO84517 <br /> . . T Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> 1. No. Type Quantlty Wt.Nol. <br /> NON-RCRA HAZARDOUS WASTE, LIQUID <br /> ( AQUF,OU° PARTS WASHER SOLUTION,' M 134 <br /> Z 2. <br /> W <br /> C7 <br /> 3. <br /> 4. <br /> 14.Spedal Handling lnstmctions and Additional information SK TRCK;110102218 0037903480 0000370102 0848 25 <br /> -l. �, r <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hemby declare that the contents of is consignment are Polly and accu .;ascribed above 6y 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 cedify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 45 CFR 262.27(a)(If I am a large quantity generator)or(b)if I am a small quantity generator)Is true. <br /> Geryeratord fferors Printed/iyped Name Signature - Mopm Day Year <br /> ^ C (t <br /> � 16 lntema66nal Shipments <br /> _ ❑Import to U.S. ❑Expert from U.S. Pod of entry/exit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.TmnsporterAcknowledgment of Receipt of Materials <br /> TraWpolter 1 Printecirfyped Name Si <br /> Y, / / Signature <br /> Month Day Year <br /> yz_ J C_ L <br /> ¢ Tran rter2 Pdnted/ryped Name' Signature Monm Oay fir" <br /> a' <br /> _} 18 Discrepancy <br /> 1 18a Discrepancy Indication Space ❑ Quantity T El Type Residue ElPart.i Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 181bGenerator) U.S.Alternate Facility(or GeU.S.EPA ID Number <br /> U <br /> LL Facilih/s Phone: <br /> W 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 2 3, 4. <br /> 28.Designated Faciiity_Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedrryped Name' Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />