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SCK SHIP# 223490998 ��//� III111111111111Iill111111llll11111111 <br /> Please print or type.(Form designed for use on elite(12-pitch)*Pffii 0 0 6 1 9 2 0 4 9 S K S <br /> t Generator ID Number Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 7 X R@@@@e: '" 2.Page t of 3.Ert�ergengy Response Phone a.AlanllesI TTnick naNru�mber �/ <br /> WASTE MANIFEST 00, <br /> O 616 2 049 SKS <br /> 5.Generato's Name and Mailing Address Generators Sue Address;A amerem than mating address) <br /> St1'LETY—KLEEN SYSTEMS, INC. <br /> �0 BOX 555 <br /> It,l P11 CA 95369 <br /> Generates Prhoneo:�e���0�9 s-545-1011 SAI_I Ciq <br /> s. 4, F 1 Y- EEN SYSTEMS INC U.S.EPA ID Number <br /> 7.Transporter 2 Company Name - <br /> U.S.EPA 10 Number <br /> B.Designated Fadtiry Name and Site Address St AFETY—KLEEN OF CAI._TFORNIA U.S.EPA ID Number <br /> 6880 SMITH AVF. <br /> N134ARK O 9456P <br /> FacrBry's Phone 10-7c)5- 4400 CAD98088741 R <br /> ga. 9b.U.S DOT Description(Including Props Shk*V NM HamN 01M.10 Nurrlher, 10.Contamers <br /> HM and Packi g Group(if any)) 11.Total 12.Und 13.Waste Codes <br /> No. Type Ouanny 'Nt'Vc <br /> s 1 NDN—RCRA HAZARDOUS W(`;TFI LTRIUIO <br /> or tISFI? f!Tt t <br /> z z <br /> W <br /> c7 <br /> 3 <br /> 4. <br /> 14.Speclal Harding Instructions and Additional Information TSD:EVG <br /> H? Fi'?'"P l�.Nl:`/ it 1 '30!1- '168-1760 (SK ,' TL:I <br /> �r" -P Tn RETAIN I TrUllclil ',lin :IRR!` " S :G y. <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare 11th the contents of this consignment are fully and accurately described above by Me proper shipping name,and are Uassified.packaged, <br /> marked and latoeledlplacarded.and are in all respects in proper condition for transport according to applicable mtemahonal and national governmental regulations.if export shipment and I am the Pnmary, <br /> Exponer,I cerofy that the contents of Nis consignment conform to the terra of the attaUad EPAAcknowledgment of Cosenn <br /> I certify that the waste minimization statement dentfed in 40 CFR 262.21(8)(if I am a large quantity generator)or(b)(if I quanury generator)is true. <br /> Generatoes'Offifes Pnntecrypeq Nan*- Signature Month Day Year <br /> J 16 international Shipments <br /> l/�►� / �� <br /> 20 Import to U.S. ❑Export from U.S. ort W entry;ezi[ <br /> Transporter signature(for exports only): .... <br /> Date lean .S.: <br /> 17.Tramp"Arknowledgmem of Receipt of Materials <br /> Cr Transpo PrintedRyped Name Signature gna Month Day Year <br /> 117 <br /> Q Tram. .en nrtedrTypetl.tame Sigrahae Month Day Year <br /> fL <br /> 18 Discrepancy I� <br /> 18a DScrepanc;Indication Space Ll Ouamr, El Type Rest. ❑Partial Rejech. C Full Rejection <br /> 18b.ARemate Facility(or Generatori Manifest Reference Nhnrber <br /> U.S.EPA ID Number <br /> J <br /> U <br /> Faabtys Ptwne. <br /> LU t k Sgratum of A comate Faalny(er Gerheratori Month Day Year <br /> a <br /> z <br /> 0 19 Hazardous Waste Report Management Method Codes(ia..codes for tlamrdous waste treatmentdisposal and recycling systems) <br /> 0 <br /> I V J <br /> 1 20.Designated Facility Nrer or Operator.Certification of rempo hazardous materials covered Dy the manifest except as need 78a <br /> Pnnted1T�a s S�gnae:re <br /> Monro Day Year <br /> �d ( I <br /> EPA Form 870D•22(Rev.3-05)Previo ditlonsare fsolete. DESIGN FACILITY TO DESTINATION STATE IF REQUIRED <br /> 1)1 1'r'49!1--L01'7 ( I <br />