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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Trackin Number <br /> WASTE MANIFEST CAL000341028 1 1-800-468-1760 100:- 3 4497 SKS <br /> 5.Genemtoes Name and Mailing Address Generators Site Address(if different than mailing address) <br /> SWISS AMERICAN SAUSAGE CO <br /> .251 Darcy Pkwy <br /> Lathrop CA 95330-8756 <br /> Generators Phone: 209-858-5555 <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY—KLEEN SYSTEMS, INC. TJ(R000050930 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, INC. U199D Number <br /> 6000 88TH STREET //GG���� <br /> SACRAMENTO + CA 95828 CA0000084517 <br /> 916-386-491u <br /> Facility's Phone' <br /> 98 9b.U.S.DOT Desorption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type !Quantity WLNol. <br /> of 1. NON—RCRA HAZARDOUS WASTE, LIQUID I DM I7 G 134 <br /> 0 (AQUEOUS PARTS WASHER SOLUTION) <br /> z 2. <br /> w <br /> 3. <br /> 4. <br /> 14.specialHandling Instructions apdAdditional Information SK SHIP#208073221 58790459 3131302 201235 CSG:22 <br /> 24 HR EMERGENCY #1-800-468-1760 (SAFETY—KLEEN — CONTRACT #94138) <br /> GK PAITHI"IRIZED Tn RFTATM I TCPtj(;rp1 ! R <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this Consignment are fully and accurately descnbed above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,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 terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262,27(a)(if I am a large quantity generator)or(b)(if I am a smal ntity genera tor)is[rue. <br /> Gene torslOfferors Printed/Typed Name Suture Mpntly Ray Year <br /> j 16.International Shipments <br /> Ll Im <br /> F, port to U.S. Export from U.S. Port of entry/exit: <br /> z Transposer signature(for exports only): Date leaving U.S., <br /> w 17.Transporter Acknowledgment of Racal p bf Materials <br /> jj TransD er 1 Printed/Typed Name Signature Mor ay <br /> Year <br /> O ' <br /> rn1 J Signature <br /> Month Day Year <br /> z Transpo er2 Ph ted(Typ d Name 9 <br /> K <br /> r <br /> _ 18.Discrepancy <br /> lBa.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue El Rejection ❑Full Rejeclion <br /> Manifest Reference Number: <br /> 181p Alternate Facility(or Generator) US.EPA ID Number <br /> J <br /> U <br /> LL Faciliy's Phone: <br /> Ow red.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Cedes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> a. <br /> 1. H141 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as n_ded in Item 1 Ba ' <br /> Pri y ed Nae > Si na re /�'� � Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. �.� DESIGNATED FACILITY TO GENERATOR <br /> 1)14941/150135 <br />