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SSL SK SHIP# 218092525 ?,7110 l/l III(I I(�I I IIII I III II+II II IIII((I(III <br /> 0 0 5 2 4 4 6 9 3 S K 5 <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 12.Pagllol 3. m se 4.Manifest Traokin Number <br /> TXR000081205 �- ��-�'�� 00 <br /> 5244693 SKS <br /> WASTE MANIFEST <br /> 5.G r m r Genera rs Address if iffe ent th n ailin address) <br /> G9409W VC P %V9TEMS, I NC. S�AF� TY—K� ESN SAY T MS, I NC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209-545-1011 SALIDA CA 95368 <br /> s.T�rT1�or�� la� 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 /> 510-795-4400 CAD980887418 <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 /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1 NON RCRA HAZARDOUS WASTE,LIQUID TT G 133 , <br /> o ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) <br /> i S-b <br /> z 2. <br /> W <br /> CD <br /> 3. <br /> 4. <br /> I <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'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desc'bed a ove 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 nab 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 96anfity generator)is true. <br /> Generator erors Printedrryped Name- Signature Month Day Year(Cl�— i v � <br /> 16.lRema7tonaMnipments <br /> ❑Import to U.S. Export from U.S P entry/exit: <br /> Transporter signature(for exports only): leaving U.S.: <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter rinted/Typed Name ! Signature Month Day Year <br /> 1611 <br /> ZZ Transpo r 2 Pnn ed/Typed Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ ❑ ❑ ❑Full Rejection <br /> ❑ Quantity Type Residue Partial Rejection j <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> LL 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 /> L 1. 2. 3. 4. <br /> V1 y 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 /> cuc y v <br /> EPff 17)(� Pft&05) Previous editions are obsolee. DE§IGNAXD FACILITYTO D (NATION STATE(IF RE UIRED) <br />