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SK SHIP# 22417900 ���0 I illlll II I IIII�II IIII IIID I <br /> 0 0 6 0 9 9 7 2 6 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.91,48 No,2050.0039 <br /> UNIFORM HAZARDOUS I 1 Generator ID Number 2.P 1 of 3 se 4.Manifest Tracking Number <br /> WASTE MANIFEST T X R000081205 �� -fr006099726 S K S <br /> 5.Generator's Name and Madmg Address Generatoes Site Addrem IN different tear,maitirg adCressi <br /> SAFETY-KLEEN SYSTEMS, INC'. SAFETY-KLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CR 95368 <br /> Generatil Phone: 209-545-1011 SALIDA CA 95368 <br /> 6� nr SYSTEMS INC; U.S.EPA ID Number TXR000081?0: <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address SAFETY-KLEEN OF CALIFORNIA U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK , CR '?r.`,6A <br /> CAD960887418 <br /> 510-795-4400 <br /> Facetys Phone: <br /> ga. 9b.U.S.DOT Description(inducting Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM a dn <br /> Pag Group(d any)) 13.Waste Codes <br /> No. Type QuantityW1Nd, <br /> 1 NON-RCRA HAZARDOUS WASTE, LIQUID TT 6 221 <br /> o (USED OIL) <br /> -t0 <br /> 2 <br /> � I <br /> 3, <br /> 4. <br /> 14.Special Handling trtatmctons and Additional Information TSD:EVG SRL. f <br /> 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) <br /> AUTH AS "AGENT-FOR" BY GEN TO RETAIN LICENSED SUB CAP,RIERS AS NECESSARY <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,pact aged. <br /> marked and Iabeled/pWcarded.and are in all respects in proper condr on for mmiro l according to applicable musmabonal and national governmental reputations If export shipment and I am the Primary <br /> Exporter,I cerbfy that the contents of this consignment conform to the terms of ere attached EPA Acknowledgment of Coasent. <br /> I certify that the waste minimization statement identified in 40 CFR 26217(a)(it I am a large quantity generator)or(b)0,1 anifla small quantity generator)is we. <br /> Generator 5 PnnledlTyped Name Signature Month Day Year <br /> J 16 Imemahonal Shipments <br /> ❑ImpM b U.S. ❑Export from U.S. X Pon of entrymfut <br /> Transporter squibrre(for exports ordy). Date leaving .S.: <br /> W 17.Transporter AdmaNedgnlent of Receipt of Materials <br /> OTransports 1 ted/Typed Name _ Signature Month Day Year <br /> z< <br /> Transpokfill21sirinhedaypedNarrif Signature Month Day Year <br /> i18,Discrepancy <br /> 18a.Discrepancy Indication Specs ❑ ❑Type ❑Residue ❑Partial Rejection ❑Full Remc!or <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(a Genarlso l U.S EPA ID Number <br /> J_ <br /> V <br /> Facddys Phone. <br /> 18c Signature of Alternate Facility(or Generator) Morin Day Year <br /> 4 <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <br /> C 1 / II 2. 3 <br /> 1 20 Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item Ise <br /> PrinmdTmed Name �}Previous editions are obsh r __ Signature Month Day Year <br /> EPA <br /> 112498700-22 <br /> 6017 obsolete. //lam/ DESIGNATE A LITYTO DESTINATION STATE(IF EOUIR D) <br />