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17-185-01 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />DISC. 00774, 1 94 ? <br />Form ADDroved. OMB No. 2050-0039 <br />JPAFd1 ffl? (11.3-05) Previous edy3ns are obsolete. 4) DESIGNATED FACILITY TO-EIMINATION STATE (IF REQUIRED) <br />1V 11 10431.2272 <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />CAD981b 38018 <br />2. Page t of <br />3. Emergency Response Phone <br />11-800-468-1760-T, <br />Manliest Tracking Number �+ <br />001551443 SKS <br />WASTE MANIFEST <br />1 <br />5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />MIRACLE MILE DRY CLEANERS <br />82 W CASTLE ST <br />STOCKTON CA 95204 <br />Generators Phone: 209-464-0411 <br />' ffV ft'fi rn`kYSTEMS, INC. U.S. EPA ID Number TXR000050930 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS, INC. 000760 U.S. EPA ID Number <br />6000 88TH STREET <br />SACRAMENTO CA 95828 <br />916-386-4913 CA0000084517 <br />Facility's Phone: <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Padang Gmup (d any)) <br />Quantity <br />Wtivol. <br />X <br />'WASTE TOXIC LIQUID,ORGANIC N.O.S. <br />DF <br />P <br />F002 <br />D007 <br />D039 <br />o <br />(TETRACHLOROETHYLENE, TRICHLOROETHYLENE) <br />D040 <br />741 <br />6.1 UN2810 PGIII RQ(F002) <br />':3 <br />z <br />2. <br />W <br />C7 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information SK TRCK#110009153 0002508564 <br />1)ERG#153 <br />SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br />15. GENERATOR'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 10 the terns 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 gene (b) (if I am a small quantty generator) is true. <br />rra!toeerors Printed(Typed Name Sign re Month Day Year <br />r / / / Q <br />J <br />I-- <br />16. International Shipments <br />try <br />El Import to U.S., El Export from U.S Port of en /exit: <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Aclknrnvledgmeni of Receipt of Materials <br />Transpo <br />rinted/Typed Name Signature Monthh Day Year <br />N/✓ <br />C d/ 7 0 8 <br />Q <br />Transporter 2 Printedflyped Name a Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Spaceb <br />❑ Quanti❑Type El 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 <br />Facility's Phone: <br />w <br />18c. Signature of Altemate Facility (or Generator) <br />Month Day Year <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes d :, codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. H141 2. tl 3. 4. <br />20. Designated Facility Own r Operator. Certification of receip of hazardous materials covered by the manifest except as noted in Item laa <br />PrintedlTyped NameSignature Month Day Year <br />S � LI oS <br />JPAFd1 ffl? (11.3-05) Previous edy3ns are obsolete. 4) DESIGNATED FACILITY TO-EIMINATION STATE (IF REQUIRED) <br />1V 11 10431.2272 <br />