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SSL SK SHIP# 214962812 P3// IIIIIIII 111 1111111111111 <br /> 0044946095 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 1 2.Page 1 of 3.Erne Re nse Phone 4.Manifest Track' Number <br /> WASTE MANIFEST TXR000081205 1 1— O —4�8-1760 004 4 4609 SKS <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209-545-1011 SAL!DA CA 95368 <br /> 6.Trans rter 1 Com n Name U.S.EPA ID Number <br /> S ETY—FiLYEEN SYSTEMS, INC. TXR000081.10 <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 '��+=f��th <br /> CAD980887418 <br /> 510-795-4400 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12 Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.NoI. <br /> 0 1 NON—RCRA HAZARDOUS WASTE, LIQUID TT i 221 <br /> (USED OIL) <br /> pct Z7 <br /> Z 2. <br /> W <br /> 3. <br /> 4 III <br /> 14.Special Handling Instructions and Additional Information TSD:EVG SAL C Iy; <br /> 24 HR EMERGENCY #1-800-468-1760 (SAFETY—KLEEN) <br /> RK QIITHART7FD T <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 a d 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 EPA Acknowledgment of Cons t. <br /> I certify that the waste minimization statement idenfified in 40 CFR 262.27(a)(if I am a large quantity generator)orJA)(if I m a small quantity generator)is true. <br /> Generator erors Printed/Typed Name Signature V Month Day Year <br /> J 16.International Shipments <br /> i— ❑Import to U S. ❑Export from U.S. nD <br /> of entrylexit: <br /> Transporter signature(for exports only)' eleaving U.S.: <br /> UJ 17.Transporter Acknowledgment of Receipt of Materials <br /> li— <br /> Transport 1 Printed/Typed Name Signature Month Day Year <br /> CL <br /> Z- i t., S <br /> z Transporter 2 Printed/Typed Name Signature �- Month Day Year <br /> Q <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ ❑ ❑Partial El <br /> ❑ Quantity Type Residue Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone. <br /> w18c.Signature of Alternate Facility(or Generator) Month By Year <br /> a <br /> Z <br /> Fn 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 ,. ^51 <br /> 2. 3. ' 4. <br /> "/� <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest ex pt as noted inyl m 18a <br /> PpNe signal Month I <br /> Iea� 1z, <br /> ` <br /> EPA Form 8700-22 Rev.3-O Previous editions are obsolete. DE IGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 1) 11249/15601 <br />