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51'. SHIP# 219155251 IIIIIII'��IIIIII�IIIIIIIIIII�IIIIIIII <br /> 0 0 5 3 2 4 2 3 2 S K S <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 2.Page 1 of 3.Emergency Response Phone 4.Manifest Track' Number <br /> TX RdE�Qt@8124 100532923-6 SKS <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> ;TEMS, INC. ":E?FEi>'-N:.!EES Sl'�TEwi , N <br /> `�05@ SALIDA BLVD <br /> "R 9536E, <br /> Generator's Phone: SALIDA CA 95358 <br /> 6.Transporter 1 Company.Name _NgTEM9, INC. U.S.EPA ID Number T v R00@0812105 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY-KLEEN OF r0.1 T rnpp;T A, I Nr U.S.EPA ID Number <br /> 6880 SMITH AVF <br /> NEWAPV <br /> 510-795-4400 'AD9�9@SP..741B <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 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wtivol. <br /> 1. "'7UN-PCRA HAZARDOUIS WASTE, I_;riJir - - <br /> o !USED OIL) <br /> Z 2. <br /> w <br /> c9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSI) EVS cr 1L. S.s:, <br /> t-Jr• r.',- occ71-71/ ffI -nh0-4b8-17E0 (SK. TFT) <br /> BY SEN TO RETAIN LICENSED SUB CARRIERS <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 labeled/placarded,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 EPAAckiowledgmeni of Cogient. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator) (b) I am a small quantity generator)is true. <br /> Gene r slOHeror s Printed/Typed Name Signature Month Day Year <br /> -..r 16.International Shipments <br /> i- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): r' Dat leaving .S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transport r 1 Printed/Typed Name Signature r Month Day Year <br /> O <br /> N lc>k4 i b c-. <br /> Q Tran iter 2 Printedfryped Name Signature Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Typej j <br /> ❑Residue El Partial Rejection Full Re ection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facilitys Phone: <br /> C3 <br /> 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. <br /> r <br /> 1 <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifeso-GN as noted in Item 18a <br /> Pri ,Wd Name Sign re Month Day Year <br /> I, CSG'/ S ✓C �- l� Z 62 117 /V <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DE!SIGNATEgYACILITYTO DESTINAT STATE(IF REQUIRED) <br />