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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 006136514SKS Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS i.Generator ID Number 2.Page 1 of 3.Emergency Response Phorre 4.Manliest Treeking Number WASTE MANIFEST 5 Generator's Name and Mailing Address Generators Site Address(if different than mailing addres,) 36514 SKS ;AFETY—KLE1-N SYSTFMs-, I Nt.. -iI] R{ig core Generator sPhone —545-1011 6.Trarl.wfl 1 Company Name MF iAf U.S.EPA ID Number �,. 7.Transporter 2 Company Name U.S.EPA ID Number 8 Designated Facility Name and Site Address SAFETY—KLEEN OF CAL TFURr,; U.S.EPA ID Number 1.880 SMITH AVE. NF'WI,'PF! -,g Facility's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class.ID Number, 1,Containers 11.Total 12.Unit HM and Packing Group(H any)) 13.Waste Codes Nc T,re Quantity Sv1 Vol. r�o 7 Z 2. W 3. 4. 14,Special Handling Instructions and Additional Information !ftl Gn1`-r--fJhY #1 -n- Af-INT--F 017, 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 Iabeledlp43prded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conbnn to the terms of the attached EPAAcknowtedgment of Corsen I certify that the waste minimization statement Identified in 40 CFR 262.27(W(if I am a large quanbly generator)or(b)(H I a II quantity generator)is true. Genera Offerors Pnntedrryped Name Signature Month Da, rear 16.International Shipments Z ❑Import to U.S ❑Export from U.S. Pun of enirytexll: Transporter signature(for exports only) Date le, g U S. W 17.Transporter Acknowledgment of Receipt of Materials Transporter1 'N 7yped Name r Signature Month Day Year IL (_ 1w p L� N QTransporter 2 PHnted.rFyW Name Signature Mont Day Year K 18.Discrepancy 18x.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Paroai R=ecuoa ❑F,;i.Rei-c- Manifest Reference Number. 18b.Atemate Facility(or Generator) U.S EPA ID Number J U LL Fac,h y's Phone: 18c.Signature ofAltemate Facility for Generator) !'crr Da., Year Q Z H 19.Hazardous Waste Report Management Method Codes if e.,codes for hazardous waste treatment disposal,and recycling systems) 1. 2 3. 4 1 20 Designated Facility Owner or Opti to Certification of receipt of hazardous materials covered by the manifest except as noted in Item lea Printedrryped Name Signature Mpnth Day Year EPA Form 8700-22(R v.3-05)Previous ed'ons are obsolete. DESIGNATED FACILITYTO D STINATION STATE(IF REQUIRED)