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7-185-01 <br />Please print or tvoe. (Form desianed for use on elite (12 -pitch) tvnewritar 1 <br />U f, S C.. ';lF- C�nnm o r'w;rm� )nrn-nnao <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are 6bsolete. DESIGNATED FAC110TY TO DESTINATION STATE (IF REQUIRED) <br />1)0012627 2) 3) 4) <br />10224.2031 <br />UNIFORM HAZARDOUS 1. Generator ID Number CAD9816 38018 <br />WASTE <br />2. Page 1 of <br />3. Emergency Response Phone. <br />Manifest Tracking Number <br />MANIFEST <br />1 <br />1-800-468-1760 <br />000585456 $K$ <br />5. Generator's Name and Mailing Address Generators 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 />6. Trans rler 1 Com n Name U.S. EPA ID Number <br />SAFETY-I�L 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. 000760 U.S. EPA ID Number <br />6000 88TH STREET <br />SACRAMENTO CA 95828 <br />916-386-4913 CA0000084517 <br />Facility's Phone: <br />90- <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WtNol. <br />13. Waste Codes <br />No. <br />Type <br />s <br />X' <br />WASTE TOXIC LIQUID,ORGANIC N.O.S. <br />DF <br />P <br />FOO2 DOO1 <br />D03 <br />O <br />(TETRACHLOROETHYLENE)6.1 UN2810 PGIII <br />RQ(F002) (`Etilt1�gA4 D007, D039, D040) <br />=3 60 <br />D040 741 <br />w <br />z <br />2. <br />w <br />3. <br />4. <br />14. Special Handling Instructions and Additional lnlonnation SK TRCK#108703087 0034697735 0002508564 0731 24 <br />'C9 73- /-R`1�t / 5-3 <br />SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br />15. GENERATOR'S/OFFEROR'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 labeledlplacarded, and are in all respells in proper condition for transport according to appfcable 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) (d I am a large quantity generator) or (b) (d I am a small quantityene atom) is true. <br />Genera eslOtferors Prime yped Name Signature Month Day Year <br />O <br />1-6. Inlemational pments <br />❑ ❑Export from U.S. Port of /ext: Lj <br />Import to UlTransporter <br />Z <br />sig re (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />IX <br />Trans"PrinledfTyped Name Signature Month Day Year <br />O <br />CL <br />y <br />1Q <br />Z <br />Tra W- er 2 Pnntedfryped Name Signa Month Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ ❑ ❑ Partial Re ection Full <br />❑ Quantity Type Residue j ❑ Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA 10 Number <br />J <br />U <br />W <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />z <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1. <br />H141 <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item Ias <br />Prin Sign Month Day Year <br />GG <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are 6bsolete. DESIGNATED FAC110TY TO DESTINATION STATE (IF REQUIRED) <br />1)0012627 2) 3) 4) <br />10224.2031 <br />