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SK SHIP# 215845456 �IIII�II�I�III�I��I�IIIIIIIIIIIIIIIII 0 0 4 3 7 4 1 3 0 S K S Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number T X R00008 i r 0`= 2.Page,1 of 3.;`m r R�s�ogse Plhe�e 0 4.Manifest Tracking Number WASTE MANIFEST tf Jro SKS S 5.Generators Name and Mailing Address T r Generator's Site Addressi(�ff different than maili address) t� J n L , L,_.: NEMS, .tvC. SAFETY—KLEE;a ,1 STMS, PO BOX 555 5050 SALIDA BLVD SAL TDA CA 95368 Generator's Phone: 209-545-1011 SAL I DA CA 9536a 6.Tr?ns�°r{`r'1`G°rr nyl�ar�ie SYSTEMS, I NC. U.S.EPA ID Number T X R000081.205 7.Transporter 2 Company Name U.S.EPA ID Number 8 Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA, I NC. U.S.EPA ID Number 6880 SMITH AVE. NEWARK , CA 94560CPD980887418 510-795-4400 Facility's Phone: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1. NON—RCRA HAZARDOUS WASTE, LIQUID o QISED OIL) CXS> S�toO Z 2. w 3. 4. 14.Special Handling Instructions and Additional Information TSD:EVG 7nl CSG: -4 HR EMER57NCY #1--800-468-1760 (SAFETY--K!_EEl>) T - ._•__' .C :,.-;.i a T^F'N��FT) ^.�.. ��.f Vit.; .F',r IU��`CSPRY 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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemab al and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmant of sen I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if 1 am a large quantity generator)or(b) I a a small quantity generator)is true. Gene�OffPd/Typed Name Signature Month Day Year 16.In ational Shipments P_ ❑Import to U.S. ❑Export from U.S. Portof entrylexit: z Transporter signature(for exports only): rDatilleavinio U.S.: W 17.TransporterAcknowledgment of Receipt of Materials Trans er 1 Printed/Typed Name Signature Month Day Year s. CL `� I U s O ZZ Transporter 2 Printed/Typed Name Signature Month Day t I-- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3. 4. y�_Vl - I 1 1 20.Designated Facility Owner or Operator:CertificAoriod receipt of hazard materials covered by the manifest except as noted in Item 18a PnntedfTy Name Signature Month Day Year EPA Fon 87 Q03(Play 3-Q, Previous edi o sareobsolete. SIGNATED FACILITY TO DESTINATION STATE(IF REQUI ED)