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SSL SK SHIP# 218092525 " l/� II��IIIII IIIIII�IIIIIIIIIIIIIIIIIII� <br /> 005244593SKS <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 T X 8000081205 2.Page11 of 3.€mise 1!b0 4.Manifest Tracki44693 <br /> Number <br /> WASTE MANIFEST 00 <br /> 524 6 9 3 SKS <br /> 5.G r m d r Genera r Address if different th n me'in <br /> address) <br /> 1�`9�W %q?9TEMS, INC. TY_ EEN S�YO MS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generator's Phone: 209-545-1011 SALIDA CA 95368 <br /> 6.TfflVP1f!YYr2rRtn&R SYSTEMS, INC. U.S.EPA ID Number T X R000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA, INC. U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK , CA 94560 <br /> CAD980887418 <br /> 510-795-4400 <br /> Facility's Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total 12.Unit <br /> and Packing Group if an Quant Wt.Nol. 13.Waste Codes <br /> HM 9 P( YU No. Type N <br /> 1 NON RCRA HAZARDOUS WASTE,LIQUID TT G 133 <br /> o ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) <br /> W <br /> i S"b <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information SAL CSG: <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 dedare that the contents of this consignment are fully and accurately des 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 intemational and nati al g emmentaf 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 EPAAcknowledgment 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)(I I am a s all ntity generator)is true. <br /> Generator era's Printed/Typed Name Signature Month Day !Year <br /> ema lon <br /> _J16.In a ipmentsEl <br /> ❑Import to U.S. Export from U.S. P entrylexit: <br /> Transporter signature(for exports only): leaving U.S.: <br /> LU 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter rinted/Typed Name Signature Month Day Year <br /> Za Transpo r 2 Pnn ed/Typed Name Signature Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantityype ❑ ❑ ElFullRejection <br /> E]T Residue Partial Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facilitys Phone: <br /> w 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> ti19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> I <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 /> "CLC y , <br /> EPff ffy(� f 05) Previous editions are obsolee. DESIGNAXD FACILITYTO D-0—(NATION STATE(IF RE UIRED) <br />