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0 <br />1 -185 -OL <br />Please print or Nce. (form designed forum on elite (12 -pitch) typewriter.) <br />46.00555.1762 <br />Farm Approved. OMB No. 2050-0039 <br />EPA Foal g7p422(Rev.3-05) Previous ediiions are obsolete. bESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />1)000s�87 2) 3) 4) .10294.0883 <br />UNIFORM HAZARDOUS 1, GeneratorlD Number <br />CAL000194471 <br />2.Pagelof <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />100103445 <br />WASTE MANIFEST <br />SKS <br />S. Generators Name and Mating Address General Site Address lit different than mailing address) <br />CENTRAL VALLEY WASTE SVC <br />P.O. BOX 241001 CHRIS <br />LODI CA 95241 9501 <br />Geneamrs Phone: 209-333-5660 <br />6. Transporter 1 Company Name <br />U.S. EPAID Number <br />SAFETY-KLEEN SYSTEMS, INC. <br />TXROOOGS0930 <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and She Address SAFETY-KLEEN SYSTEMS, INC. 000760 <br />U.S. EPA ID Number <br />6000 88TH STREET <br />SACRAMENTO CA 95828 <br />916-386-4913 <br />CA0000084517 <br />Faclli sPhone: <br />9e. <br />9b. U.S. DOT Desolption (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Cents, <br />ens <br />11. Tolal <br />12. Unit <br />13, Waste Codes <br />No. <br />Type <br />HM <br />and Pal Group if any)) <br />Quant y <br />WtNol. <br />W <br />NON RCRA HAZARDOUS WASTE,LIQUID <br />DM <br />342 <br />ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) <br />/ <br />Z <br />2 <br />w <br />3. . <br />4. <br />14. Special Handling Instructions and Additional information SK TRCK$109372481 0002633853 <br />SK AUTHORIZED 0 RETAIN LICENSED <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, aid are classified, packaged, <br />marked and Iabelediptaanded, and are in all respects in proper condition fa transport according to applicable international and national governmental regulations. If export shipment <br />and I am the Primary <br />Exporter,1 cerky that the contents of this consignment conform to the teams of the attached EPAAcknowledgment of Coma <br />" <br />I wary that the waste mirnmGadon statement ideal in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is we. <br />GeneratorgOfferm's Pdntedlfyped Name SigraNre <br />Month Day Year <br />EZ -V114 ' ZB► Vf12A- <br />/� 0 <br />_r <br />F <br />16. International Shipments <br />❑Importm LLS. ❑Export man U.S. Port of entrylexit: <br />2 <br />Transporter signature(for exports only): Date leaving LLS.: <br />W <br />IT TanseaderAompvdedgment of Rempl of Materials <br />C <br />Tease,Mr 1 teNTyped Name Signal ure <br />Month Day Year <br />N <br />Js✓ <br />Q <br />Transporter z Frateal PrateName Signature <br />Momh Day Year <br />K <br />18. Discrepancy <br />i <br />Ise. Discrepancy Indication ❑Residua tion Span - <br />❑ ❑ <br />❑Partialftjectlon <br />Fail R ❑ ejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or General <br />U.S. EPA ID Number <br />J <br />V <br />Facllitys Phone' <br />w <br />led. SignaNre ofAllemate Faciiry(or General ;� <br />Month Day Year <br />i <br />N19. <br />Hazardous Wage Report Management Method Codes (.e., codes for hazardous wage eeatmenL disposal, and recycling systems) <br />' <br />0 <br />1' H 141 <br />2 3. <br />4. <br />20. Designated Faoliry Owner or Operator. Cerefil of receipt of hazardous materials covered by the mended except as ed in em laa <br />PnnI Na Bgna <br />Month Day Year <br />j O <br />EPA Foal g7p422(Rev.3-05) Previous ediiions are obsolete. bESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />1)000s�87 2) 3) 4) .10294.0883 <br />