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SSL SK SHIFT# 218092525 <br /> 0052446935 KS <br /> Please print or type.(Form designed for use on elite(12•pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number TXR00>1210 ,, dpo' 3 1 <br /> se qt bo 4.M005214693 <br /> nifest Trackin Number <br /> WASTE MANIFEST 0 0 5 2 1 4 6 9 3 SKS <br /> 5.G r m d I' r NnelROM [dr(6ess(if diHe ent thanilio address) <br /> G99�VbYW'9�9TEMS, INC. EETN SY TEAMS, INC. <br /> PO BOX 555 (('I�ST I $ Z�IP0511 SALIDA BLVD <br /> SALIDA CA 953A <br /> Generator's Phone: 209-545-1011 1 SALIDA CA 95368 <br /> 6.TSrfe l f o—rpLCtIV SYSTEMS, INC. U.S.EPA ID Number T X R000k 81 c ry <br /> Nr_nfTfq f_Y:: ARTlVIENT <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFOR" IA, INC. U.S.EPA ID Number <br /> o88t?I SMITH AVE. <br /> NEWARK CA 94560CAD9808874]8 <br /> 510-795-44 11 <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT 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 /> No. Type Quantity Wt.Nol. <br /> 1. NON RCRA HAZARDOUS WASTE,LIQUID TT G 133 <br /> o ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) <br /> a - <br /> U <br /> z 2. <br /> U <br /> O <br /> 3 <br /> I. <br /> 14.Special Handling Instructions and Additional Information SAL <br /> 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) ` <br /> AUTH AS "AGENT—FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desc'bed a ve 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 nali al g emmental 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 identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a s all Antity generator)is true. <br /> Generators fferorsPrinted/TypedNance— Signature Month Day Year <br /> J 16.Interna ional ipments <br /> Z ❑Import to U.S. ❑Export from U.S. P entry/exit: <br /> Transporter signature(for exports only): leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter rinled/Typed Name Signature Month Day Year <br /> O `� { <br /> CL <br /> zQ Transpo er 2 Pnn ed/Typed Name Signature Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.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 /> U_ Facility's Phone: <br /> w 18c.Signature of Alternate 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 /> U t. 2. 3. 4. <br /> o <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Print /Typed Name Signatur Month Day Year <br /> EPf f1�rre17ftg& &05) Previous editions are obsole e. DESIGN 'D FACILITY TO DE&INATION STI,T r�' ) <br />