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r o/ Please print or type. Farm designed for use on elite (12 -pitch) typewriter.) - &C. 00S61_ 0016 Farm Approved. OMB No. 2050-0039 1 0019012 ( e )3 0034271ed3o�s 01 bsol t 4) I DESIGNVD FACILITY TO GENERATOR STATE (IF REQUIRED) 1)035701/2273902-1 2)9025803/2408467 10354.105917/40081438 UNIFORM HAZARDOUS 1. Generator lD Number CAL000194471 r. 2. Pagelof .1 J. Emergerxy Response Phone 4. Manifest Treckln Number u� �/�+ ®®1®4462 SKS . ,WASTE MANIFEST 1-800-468-1760 5. Generators Name and Mailing Address Generators Site Address; (it different then mailing address) -CENTRAL VALLEYkHASTE SVC P.O. BOX 24100f,. - CHRIS LODICA 95241 9501 209— 3 3 4=t'fi 6 0 GeInreprqastpoyr`s�Prh)onCeq:� sSAI YS—T, EMS, INC. U.S. EPA ID Number TXR000050930 T. Transporter 2 Company Name U.S. EPA ID Number s. Designated Fool Name and Site Address SAFETY—KLEEN SYSTEMS, INC. 000618 U.S. EPA ID Number 1722 COOPER CREEK ROAD DENTON, TX 76208 940-483-5200 TXD077603371 Facility's Phone: ga, 9b. U.S. DOT Desorption (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Tob it ` -12. Ung 13visors Codes No. Type HM and Packing Group (if any)) Ouantlty WWol. X 1RQ HASTE PETROLEUM DISTILLATES, N.O.S. DM P D001 D008 D018 ote (DIESELF GASOLINE) 213 211H UN1268PGII (DO01) / 5_0 = X 2HASTE SOLIDS CONTAINING FLAMMABLE DM P D001 D018 213 LIQ17D,PC IIS. (GASOLINE, BENZENE) 4.1 ®® 409 JNON RCRA HAZARDOUS HASTE SOLID DM P 352 OUTS (ABSORBENT AND OIL) 4. 14. Special Handling Instructions and Additional Info—ton SK TRCK0109374433 0002633853 1)ERG0128;2)ERG0133 SK AUTH'D TO USE SUBSE UE14T CARRIERS: 41078 41471,81681,82739 85399 15. GENERATOR'SIOFFEROWS CERTIFICATION: Ihereby declare that Ne contents of Nis consignment are fully and accurately desrxibed above by the proper shipong name, and are classified, packaged, marked and Iatmedlplacarded, 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 cattle that Ne contents of this consignment conform to the teems of the attached EPAAcknoWedgment of Consent. I ceAfy that the waste minimization statement identified in 40 CFR 26217(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. GeneratorslOfferoe P ntedrryped Name - Sign Monty Day Year VIA z,<PvA-LA ® -7 09 F 16. International Shipments❑ Export from U.S Port of an ❑ Import to U.S. hy/exiL Transporter signature (for exports only) Date leaving U.S.: W 17. Transporter AcknoMedgment of Receipt of Materials TrmuipoVA I PrntedlTyped Name signature Monro ,, e eDay yYear = a Trefisporter2Prensill ams Signa Month Day Year eve. Kc Zar 18. Discrepancy I8a. Discrepancy Indication Space [I Quantity Elva, ❑Residue artial Rejection El Full Rejection Manifest Reference Number. 18b. Altemare Facility (or Generator) - U.S. EPA ID Number J U u, Faciiys Phone's 18c. Signature of Alternate Facility for Generator) Monne Day Year a ' z 19. Hazardous Waste Retain Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1. 2. 3. 4. la w I w 20. s' ted Facility Owneror Ope2tor Cerfificittion of receipt of hazardous materials covered by the mann a pt as noted in Item IBe 111 Pn yp� / Si M Qay Yeay 1 0019012 ( e )3 0034271ed3o�s 01 bsol t 4) I DESIGNVD FACILITY TO GENERATOR STATE (IF REQUIRED) 1)035701/2273902-1 2)9025803/2408467 10354.105917/40081438