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02/12/2016 FRI 14: 06 FAX U00v004 <br /> BSL SK SHIPI4 214087011 1 �IIIII�Iill�1111���llll�llll��l�l��il <br /> { o 0 4 4 7 0 4 0 2 5 K 3 <br /> Please pitnt or type. Form deal nod for use on ellte 12• Itch t ewomr. Form Uproyad.OMB No-2050-0039 <br /> UNIFORMHAZARD0U8 Il-Genorgm ID Num or CAD983639394 z PILTIor 3— f06po�H0ypgnoITA oeo 4 1 6bef ��� <br /> WAVEMA41FU 7 1 VV 90tf /Gl/ T402 <br /> 5.Gonorotoys Name an Malllgg AdQr��a tlane m la age pIditlerant than me Iing address} <br /> StocktOTI ORISV <br /> 6tocktonm ,B Rd CA 9520--861 ` <br /> Ganeiswe Phone: 209-946-0674 <br /> a_ Ct ISYSTEMS. INC. MAKu. . um er TXR00001 1209 <br /> 1 Transporter 2 Company Name EENy�(p I R O�jI\f M EIV TA U.B.EPA 10 Hvrnfiar <br /> � O DealIjna%d Facilly Name er>dBlleAddraaa SAFETY-4tLEEN OF CALIFORNIA, INC, <br /> D, . PA ID Number <br /> 680 SMITH AVE, <br /> Si3O�795Maa00 CA 945b0 <br /> N'UARK CAD960097419 <br /> FecYll c phone' <br /> 9a 9b.U,8.DOT lA1WIDrlon(Inolualno Proper Bhlppinp Name,Herard Class.ID Number, 10 Conlalnom 11.Total 12.Unit 13.Weele Codes <br /> No, a quanlYy Wt Abl. <br /> }� and Packing Gap(d any)) T T 0 ,�33 <br /> 1.NON RCRA HA2A D U8 WASTfr r LIQUID <br /> ETHYLENE GLYCOL 89LUTION LESS THAN 50%) <br /> OtQ <br /> 2 <br /> s. <br /> EWEMERGENCY <br /> UC tool bn ion al lnlo644 3062 2014 CS 0# BOgp-468-1760(SAF'ETY-KLEEN 94138) <br /> ZE=D TO RETAIN LICENSED SUBSEQUENT CARRY RS AS NECESSARYOENf�lRO.1 CERTIFICATION: I he...1111111111111111 reby declare Ihal the oonleno of Idle consignment aro my and occuralely dncrl mu elwve by Ihs proper alUppinp Hama,end aro daselMd,paekagad, <br /> marked and Iabaledlplerarded,and aro In TIall N! lite In propor s tliscondition for IranapOrl aunrding m eppl Debts International aftd natkxiel garemmanlai equladona.Il export shipment end I am the Primary <br /> Expo Wr,l tertlfy that the coMants of Uda oonelgnmenl conform to the lerme or gra ellached EPAAoknOwladgmenl of COneenl. <br /> I c ON that the wade mintmlmlton statement IdshtMad In a0 OFR 292.2T(al(If I aro a large quenUly generator)ar(b)(HI em a smell gU1nUd ganerolor)16 true. O <br /> na <br /> Gene�PfjWl10.nExp horn U S. <br /> Port of envyhnll: <br /> import to U 8, to leaving U.9,: <br /> Traneporler signature(to(exports only) <br /> 17.Trensporler Achnowfed0mem of Receipt Of IAlelenate on osy ear <br /> Eilgnaluro <br /> renepo f rota NB nO <br /> �• Month YON <br /> Slgnaluro <br /> trap; r ole ams <br /> t14�b. <br /> Discrepancy ❑periml ReJeplon ❑Full Ralsotlon <br /> ❑Type ❑Residue <br /> epenc7lndkatlo:3pacme ❑ Quantity <br /> Men k f renes Num r'. <br /> U.S.EPA ID Ntimbe <br /> mato Pati(or(lenamfor <br /> on IBy ea <br /> PeGll s Phone: <br /> c, rlawre or wwr_.Feoillly(Or naromr <br /> !%! <br /> ele Rayon MahaOemem Method CAfNe U.e-,codes tOr ty[ardoue-was ,, dlapoeel,and rooyoling eyelenul 4 <br /> 2. <br /> 3, <br /> atly Owner Or Operator Cer1111e1i0n d reoalpl of harsrdouMa��ggO6! Prevlousedllbnsareobsolete, DE ONATED FACILITY Td DESTINATION STATE(IF Rekowl,I D) <br /> OJ <br />