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�� �'���$ IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII <br /> SSL SK SHIP# 224220483 0 0 6 3 2 5 0 9 7 5 K S <br /> Form Approved.OMB No.2050-0039 <br /> Please print or type.(Form designed for use on aide(1201ch)typewriter.) <br /> 1 Generator 10 Number 2 Pae 1 of 3 Eme enty R se P 4.Manliest Traekl NumWr <br /> UNIFORM HAZARDOUS TXR000081205 1-8�0-4 '�"1 � 0 0 6 3�Z 5 0 9 7 SKS <br /> WASTE MANIFEST <br /> 5.Generalofs Name and Mailing Address Generaws Sive Address(8 dfierem Man mailing add,— <br /> SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 CA 95368 <br /> 20 -1011 SALIDA <br /> Generators Phone 9-545 U.S.EPA ID Number <br /> B SRA ETY WSYSTEMS INF <br /> TXR000081205 <br /> US.EPA ID Number <br /> 7.Transporter 2 Company Name . <br /> 8.Designated FacdN Name and Site AddressU.S.EPA ID Number <br /> SRFETY—KLEEN OF CALIFORNIA <br /> 6880 SMITH AVE. rA 34550 <br /> NEWARK C <br /> 510-795-4400 AD980887418 <br /> Face s Phorxe: <br /> 8b.U.S.DOT Description(including Proper SNpping Name,Hazard Class.ID Number, - - T 12.Unit Q.Waste Codes <br /> 9a. 11r r �..�;�w, WLW <br /> HM and Packing Group(A any)) <br /> ore "NON—RCRA HAZARDOUS WASTE, LIQUID fT 6 221 <br /> o (USED OIL) <br /> WZ 2 <br /> lu <br /> t9 <br /> 3. <br /> 4, <br /> 14 S61Handling Instructors and Additional Information TSD:FVG SSI-- CSG: I <br /> 24 HR EF¢RGENCY #1-800-468-1760 (SK / TFI) <br /> 15. OEIIIERATOR'SIOFFEROR'S CERTIFICATION:l hereby dec:are that he contents of mus consignment are fully and accurately described above by the"per shipping name,and are classified,packaged. <br /> marked and labeleeplacarded.and are in all respects in proper condition for transport according to applicable international and national governmental regulationstf export shipment and I am the Primary <br /> Exporter.I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of nt aerator)n true. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(8 I am a large quay ry generator)or(b)' am mall quantity 9e Month Day Year <br /> Gener rsORerors P me(17)VdName Signature <br /> l �U <br /> 1 <br /> 16 mlemati0nal mpments LJimportto U S. ❑Export from U.S. Pod of entrylexit _ <br /> m' D U.S.- <br /> Transporter Signature(for exports OnY -v <br /> w 17.Trans AcknoMedgmeril of Receipt of Materials <br /> Trans[xxner Pnnted�Typetl Name_ Signature Montt! Day Year <br /> o L"Z--LLg 118 <br /> 'niZ nen 2 Primed.Typed Name Signature Monts Day Year <br /> Q <br /> 111 18.Discrepancy <br /> 1 IM Dkwepany lndicetion Space ❑Ouanot) El Type ❑Residue Partial Rejection ❑Full Rejacton <br /> IManifest Reference Number, <br /> U.S EPA ID Number <br /> 16b.AAemate Facility(or Generator) <br /> V <br /> LL Faaliry's Phone. Monts Day Year <br /> W 1&.Signature of Altemate Facility(or Generator) <br /> Q <br /> Z <br /> y19.Hazartla:sReport Management McNod Codes(i.e.,codes for hazardous waste treatment.disposal.and mn'clm9 systems) <br /> C I 2 3 4 <br /> 20.Designated Facility Owrer or Operator.Cercficetion of mor ipf of hazardous materials covered by Me manifest except as I' � Month Day Year <br /> 1 nnWyped Name Signature <br /> t�CC o2 15 (Sri <br /> IS <br /> EPA FoTTn 8700-22 11249/1990'17' Previous cnsareob ate DESI N ED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />