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SSL SK SHIP# 216115137 p?l/ y 11111111111111 1111111111111 0 0 4 7 6 4 6 6 6 S K S 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 TX R000081205 2 Pagett of 3.�meatoctc R�s�op6e P.hclw 0 1,.Manifest Tracking Number WASTE MANIFEST tSYJ� rJ t b 004764666 S K S 5.Generator's Name and Mailin Address Generator's Site Address ffif different than mailin address) SAFETY—KLEEN SYSTEMS, INC. SAFETY-0EN SYST�MS, INC. PO BOX 555 5050 SALIDA BLVD SALIDA CA 95368 Generator's Phone: 209-545-1011 SALIDA CA 95368 6.Trt?cop ffornpanu-Dlaroa SYSTEMS, INC. U.S.EPA ID Number TX R000081205 7.Transporter 2 CompanyNameU.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 510-795-4400 CAD980887418 Facility's Phone: ga 9b U S.DOT Description(including Proper Shipping Name.Hazard Class.ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity WtNol. 1. NON—RCRA HAZARDOUS WASTE, LIQUID TT 6 221 o (USED OIL) M 2. W 3. 4. 14 Special Handling Instructions and Additional Information TSD:EVG SAL CSG: , 24 HR EMERGENCY #1-800-468-1760 (SAFETY—KLEEN) SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY 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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international an ational governmental 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,ponsgoill. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or (if I, a small quantity generator)is true. General s/Offeror's Printed/Typed Name Signature Month Day Year .j 16.Intemational Shipments ZImport to U.S ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Daip leapg g U.S.: w17 Transporter Acknowledgment of Receipt of Materials Trans er 1 Firm ted/ryped Name Signature Month Day Year Ko ` oT 2 % QTransporter 2 PrintedTyped Name Signature Month Day Year H 18 Discrepancy 18a.Discrepancy Indication SpaceEl Quantity Type ❑Residue ElPartialRejection ❑Full Rejection ❑ Manifest Reference Number: IZ 181b.Alternate Facility(or Generator) U.S.EPA ID Number J U rai Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) 0 1.2 . 3, 4. O 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pnntedrl d ame, v� Signatu Month Day Year L f 2 L EPJF)of 0j7ftfD15% reviouseditions are obsolete. DE GNATED FA 1TY10 DESTINATION STATE(IF REQUIRED)