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7-185-01 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000087982 O 0 g 213"17855 <br /> �1 O 5 5 SKS <br /> 1 I-800-458-1760 V 1 O a7f�a7 <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> SAN I PAK INC <br /> PO BOX 1183 23535 S BIRD RD <br /> TRACY CA 95378 <br /> Generators Phone: 209-635-3104 <br /> s.Tr rtyl,lf rgpan ya SYSTEMS, INC. U.S.EPA ID Number TXR000050930 <br /> 7.Transporter <br /> P2Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS, INC. 00061$ U.S.EPA ID Number <br /> 1722 COOPER CREEK ROAD <br /> DENTON, TX 76208 <br /> Fadlit}rs Phone: 940-483-5200 TXD077603371 <br /> ga 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)) <br /> No. Type Quantity Wt.Nol. <br /> X'- HAZARDOUS WASTE LIQUID, N.O. S. DM P D005 DO06 D00 <br /> o <br /> (CHROMIUM, LEADg 9 NA3082 PG III <br /> X D003 221 OUT <br /> LU <br /> 3. <br /> 4. <br /> 14-Special Handling Instructions and Additional Information <br /> SK TRCK> 109671176 0000962949 <br /> 1)ERG#171 .` W. ,- I <br /> SK AUTH'D T3 USE SUBSEQUENT CARRIERS: 41078 41471. 81681 82734 85399 <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 EPAAcknowledgment 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 small quantity generator)is true. <br /> Generators/Offerors Pdntedgxped Name;1 Si nature Month Day Year <br /> c1 <br /> '�/•: w, { <br /> 16.International Shipments <br /> H El Import to U.S. El Upon from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Tr-.mu iter 1 Printed/Typed NWe Si r r Month Da Year <br /> CL <br /> QTransporter 2 Printed/Typed Name Signatu Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quantity E Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL FacWs Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> ILD <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ C 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prmtedffyped Name Signature Month Day Year <br /> Ell1)o 5Ty-JTev2 ,05 4Prev' editio>_1s)are obsolete. 4) GENERATOR'S INITIAL COPY <br /> Ell <br /> t22`�4 s <br /> 1 )200178218/ 027547 <br />