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7-185-01 <br />Please print or type. (Form designed for use on elite 02 -Ditch) tvoemiter.) <br />00189.1197 <br />Form Annrnvnrf nmR Nn gi-Irm ma <br />lE) 001 L 6 2a7 Pv. T 051 Pr v itjons are obsolete. 4) DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />2 `H�� 1 10101.0134 <br />UNIFORM HAZARDOUS <br />1 Generator ID Number <br />CAD981638018 <br />2. Page 1 of <br />3. Emergency Response Phone <br />1000240869 <br />4. Manifest Tracking Number <br />SKS <br />WASTE MANIFEST <br />5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />MIRACLE MILE DRY CLEANERS <br />82 N CASTLE ST <br />STOCKTON CA 95204 <br />Generators Phone: 2 0 9— 4 6 4— 0 411 <br />6. Transporter i Company Name U S. EPA ID Number <br />SAFETY-KLEEN 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. 000760 U.S. EPA ID Number <br />6000 88TH STREET <br />SACRAMENTO CA 95828 <br />916-386-4913 CA0000084517 <br />Fecilis Phone: <br />ga_ <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 Patting Group (if any)) <br />Quantity <br />WtfVol. <br />X <br />TASTE TOXIC LIQUID,ORGANIC N.O.S. <br />DF <br />P <br />F002 007 039 <br />o <br />(TETRACHLOROETHYLENE)6.1 UN2810 PGIII <br />D040 711 <br />w <br />RQ(F002)(13#/G)(ERG153)(D007,D039,D040) <br />Z <br />w <br />0 <br />810 PGIII <br />rDO4O 41 <br />3. <br />4. <br />14. Special Handling Instructions and Adddionallnforrnalion SK TRCK#108323523 0033893900 0002508564 0713 24 <br />SK AUTHORIZED RETAIN LICENSED SUBSEOUENTNECESSARY <br />15. GENE RATOR'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 EPA Acknowledgment of Consent. <br />l certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity gene r (b) (if I am a small quantity generator) is true. <br />GeneratorsrOHerors Printedrryped Name S' re Month Day Year <br />103 1 Z7 07 <br />J <br />F <br />16. Inte tions Shipments Ex fro .S. Pod of en /exR: <br />❑ Import to U.S. ❑ pot try <br />= <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter dntedriyped Name Lu a Month Day Year <br />a <br />L c 03 1 Z7 07 <br />QTran <br />nen 2 Printed/Typed Name re Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity El Type Residue Partial Rejection D Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />rag <br />Facility's Phone: <br />Lu <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />z <br />H19, <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />c <br />1. H 141 <br />z. n <br />3. <br />a. <br />20. Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest exce t as noted in Ite <br />Printedrryped Name —S Month Day Year <br />lE) 001 L 6 2a7 Pv. T 051 Pr v itjons are obsolete. 4) DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />2 `H�� 1 10101.0134 <br />