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SSL SK SHIP# 218092525 P J�// II I Il I II I I'll I IIII 11 III II III)I II I III 0 0052445935 KS 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 ROOOOB 1205 2 Pagett of 3-fM R4W TIMO 4.Manifest Trackin Number WASTE MANIFEST 0 0 5 2 4 4 6 9 3 SKS 5 G r m r Generat i Si Address if different Ih n n 'in address) MO L2` 0 V79TEMS, INC. SAF TY—K EEN S�YSTMMS, INC. PO BOX 555 5050 SALIDA BLVD SALIDA CA 95368 Generator's Phone: 209-545-1011 SALIDA CA 95368 6.T ey*orRE&R SYSTEMS, INC. U.S.EPA ID Number TXR000081205 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA, INC. U.S.EPA ID Number 6880 SMITH AVE. NEWARK , CA 94560 CAD980887418 510-795-4400 Facility's Phone: 9a 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.Not 1 NON RCRA HAZARDOUS WASTE,LIQUID TT G 133 o ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) z 2. w c7 --- — 3. I i 4. j 14.Special Handling Instructions and Additional Information SAL CSG 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) AUTH AS "AGENT—FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY 15. GENERATOR'S/OFFEROR'S CERTIFICATION: 1 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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and nett al g __mental 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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(if I am a s allentity generator)is true. Generator's eror's Printed/Typed Narr,- Signature Month Day Year -J 16.Interna lona ipments H ❑Import to U.S. Export from U.S. i/entry/exit: Transporter signature(for exports only): ang U.S.: W 17,Transporter Acknowledgment of Receipt of Materials R Transporter rinted/Typed Name ! Signature Month Day Year Nct�..s �. 16111si 1(,-- Z Transpc r 2 Pnn ed/Typed Name Signature Month Day Year F 18 Discrepancy 18a.Discrepancy Indication SpaceResidue ❑ Quantity El ❑Type EJ Partial Rejection Full Rejection Manifest Reference Number: 18b.Altemate Facility(or Generator) U.S.EPA ID Number J_ V LL Facilitys Phone: Lo 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z gE �%Pdjj-05) ous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyding systems) 3. 4. ated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a ed Name Signatur Month Day Year �-C Previous editions are obsole e. DESIGNWD FACILITY TO D INATION STATE(IF RE UIRED)