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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZAR enerator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST '4TUS)'0610�4Y SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> %JVL� it{t�h"titi <br /> 400 W VALP1CO RD <br /> TRACY CA 95376 919- <br /> Generator's Phone: .1 .1 .``' `.1971 <br /> 6..Tran5tler 3 CornpgrV Nome- U.S.EPA ID Number <br /> --5AF ' . Lt:-k v-,'6 i LMS, INC. <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 IDNumber <br /> 6000 SOTH STREET <br /> 116-306-4913 SACRAMENTO CA 95828 CAQOC�QQ94517 <br /> Facility's Phone: <br /> ya 9b.U.S.DOT 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 WLN01. <br /> 'NON-KRA 14AZAR€OUS WASTE LIQUID D" 34 <br /> o <br /> (AQUEOUS PARTS UASHER SOLUTION) <br /> 4 <br /> rY <br /> Z 2. <br /> W <br /> (7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional information SK TRCK#F109120965 0035622567 0000370102 080:1 ?1 <br /> r 'r ";;JMEO <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 /> marked and labeledlplacarded,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 certify that the waste minimization statement identffled in 40 CFR 262.27(a)(if i am a large quantity generator)or(b){if I am a small quantity generator)is true, <br /> G nerator'slOSerars PrintedlTyped Name Signature Month Day Year <br /> J 16.International Shipments <br /> F— ❑ImPort to U.S. ❑Export from U.S. Port of entry7exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17,Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Na Srgnatu / Month Day Year <br /> a <br /> QTransp6rter 2 PrintedlTyped NarTiF3 Signature. Month Day Year <br /> I- <br /> 1 S.Discrepancy <br /> 1 Sa.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> U <br /> uu- Facility's Phone: <br /> LO 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> r— <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 12. 3. 4. <br /> 20.Designated FacilityOwner or-Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> P' Name 6] Si nature Month Day Year <br /> d ?-; <br /> FF� 4 f(�ei j.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />