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g'��� IIIIIIIIIIIIililllllllllllllllllill <br /> SSL SK SHIP# 216895568 <br /> 0 0 5 0 2 8 8 2 7 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emer en Res nse Phone 4. nr s rn Nu <br /> WASTE MANIFEST <br /> TXR000081205 1 1-806 4r8-1760 2 7 S KS <br /> 5 Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone. 209-545-1011 SALIDA CA 95368 <br /> 6 Tran iter 1 Com an Name U.S.EPA ID Number SNFo ETY—(L EN SYSTEMS, INC. TX R000081 c05 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA, INC. U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK , CA 94560 <br /> CAD980887418 <br /> 510-795-4400 <br /> Facility's Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers LQuantity <br /> otal 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No Type Wt.Nol. <br /> 1 NON—RCRA HAZARDOUS WASTE, LIQUID TT G 221 <br /> of (USED OIL) OG � <br /> og <br /> z 2. <br /> LJ <br /> 3. <br /> 4. <br /> 14,Special Handling instructions and Additional Information TSD:EVG SAL CSG: <br /> 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) <br /> UTHnR17FD AS rr _ rr FIV - <br /> rESSARY <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,packaged. <br /> marked and labeled/placarded,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 <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPA AcknowledgmentCon nt. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)ort(if I m a small quantity generator)is true. <br /> Genera slOtferors Printed/Typed Name Signature Month Day Year <br /> J 16.Inlemational ShipmentsEl <br /> El Import to U.S Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): ateVaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> W Transport 1 Printed/Typed Name Signature c Month Day Year <br /> Name.- <br /> 0 f� 1.3' <br /> N Month Day Year <br /> Q Transporter PnnteVyped Name Signature <br /> 18.Discrepancy <br /> 18a Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: Month Day Year <br /> UJ 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 _1 "'7 ]2. <br /> V <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifes pl as noted in Item 18a <br /> Print yped Name Signa Month Day Year <br /> o(1 ` S ��c ��Z Jv � S <br /> EP Form <br /> 11 700-22 601�Previouseditionsareobsolete. DESIGN D FACILITYTO DESTI TION STATE(IF REQUIRED) <br />