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7142lI��I �III�v�{�III� NIJ,III III <br /> 0 0 2 4 2 4 9 9 3 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Pae 1 of 3.E r envy Re nse"m <br /> o 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS umCAL000127342 �. 1 �C�O-4b�—l�d'b <br /> WASTE MANIFEST 002424993 SKS <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> MIRACLE AUTO PAINTING <br /> 1251 E BIANCHI RD <br /> STOCKTON CA 95210 <br /> Generators Phone: 209-474-3372 <br /> 6.Trans iter 1 Com an Name U.S.EPA ID Number <br /> SAFETY—K�E�EN SYSTEMS, INC. TXR000050930 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, INC. 7221 U.S.EPA ID Number <br /> 6000 88TH STREET <br /> SACRAMENTO CA 95828 <br /> 916-386-4913 CA0000084517 <br /> Fadlilys Phone: <br /> 9a 9b.U.S.DOT Description(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 Wtivol. <br /> X ' RQ WASTE PAINT RELATED MATERIAL DM P FOOS F003 001 <br /> 0 3 UN1263 PG II (D001) <br /> D028 D035 212 <br /> z y 2. -ER4A4 9, 0 <br /> LUIAT <br /> C7 �-r — <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Information SK SHIP#200293945 50323700 963018 201014 CS13:24 <br /> 1)ERG#0128;•'—)ERG#0128; <br /> 24 HR EMERGENCY # 800-468-1760(SAFETY—KLEEN — 94138) <br /> SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,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 EPAAdmowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 252.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generato slOfferor's Printedliyped Name I Signature Month Day Year <br /> J16.Inteatio al Shipments <br /> F. m ❑Impart to U.S. ❑Export from U.S. Pon of ntry/exiT. <br /> Transporter signature only): Date leaving U.S.: <br /> CC 17.Transporter A edgment)Receipt of Materials <br /> LU <br /> Transporter 1 P ted/Typed s Signature Man Day Y r <br /> O <br /> a �. <br /> i Transporter Pn Name r Month Day Year <br /> Q <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type �� ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Allemate Facility(or Generator) U.S.EPA ID Number <br /> J , <br /> U <br /> U6 Facilitys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> ZZ <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU t. 2 3. 4. <br /> "I'Al - <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except"ed in Item 18a <br /> llw�ped�am <br /> Signature,/,-/ Month Day Year <br /> r <br /> EPA o 8700-22(Rev.3-05) Previous a itions are obsolete. ESIGNAT FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 1)12606/150425 10697.0753 <br />