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7-185-01 Please print or type. (Form designed for use on elite It 2 -pitch) twewriter.l DITS.C. f:t19,13.39. 2.280 car,,, ennrn d nMR Nn )nr"nzo 1�P�O l 187D(k22 fRev. 3 Q5] PW6ges JTons are obsolete.. 4 ) 00026.1148 DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) 0013 31 HAZARDOUS ,I�YASTEMANIFEST 1. Generator ID Number2. CAD981638018 Page 1 ofF3.Emergency Response Phone 4. Manifest Tracking Humber CEX ll-Ron-4fic 1760 000166939 IUP"FORM 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) MIRACLE MILE DRY CLEANERS 82 W CASTLE ST STOCKTON CA 95204 Generalor's Phone: 2 0 9— 46 4— 0 411 6. Transporter 1 Company Name U.S. EPA ID Number SAFETY-KLEEN SYSTEMS, INC TXR000050930 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS, INC. 000760 U.S. EPA 10 Number 6000 88TH STREET SACRAMENTO CA 95828 916-386-4913 CA0000084517 Facility's Phone: ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit Waste Codes No. Type HM and Packng Group (if any))13. Quantity WWoI. X kASTE TOXIC LIQUID,ORGANIC N.O.S. DF P F002 007039 of TETRACHLOROETHYLENE)6.1 UN2810 PGIII D040 741 Q( F002)( 13#/G)( ERG#153 ){ D007, DO 39, D040) ;360 w ,= X ASTE TOXIC LIQUID, ORGANIC, N.O.S. DF P F002 007 1039 (TETRACHLOROETHYLENE)6.1 UN2810 PGIII D040 741 3#/G(ERG#153)FILTERS(FO02DO07DO39DO40) Z Q 1 3. 4. 14.SpecialHandling Instructions and AdditionalInformation SK TRCK#107838405 0032870174 0002508564 0642 24 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, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and rational governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (f I am a large quantity generator) or (b) (if I am a small quantity generator) is We. Gen Offerors Pdnted7yped Name Signatu Month Day Year h �= I V01/ 06 —J F 16. International Shipments . ❑ Import to U.S. ❑Export from U.S. Port of entry/ex t Transporter signature (for exports only): Date leaving U.S.: 12: 17. Transporter Acknowledgment of Receipl of Materials Trans rter 1 Pnnted/Typed Name Signature Month Day Year N C / 06 Z Q Transporter 2 Printed/Typed Name S g lure Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection r Manifest Reference Number. 18b. AJtemale Fadlity (or Generator) U.S. EPA ID Number J V LL Facility's Phone: w 18c. Signature of Altemate Facility (or Generator) Monty Day Year Q Z y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) W 1. H141 2' H141 3 a. 20. Designated Fad' er or Operator. Certificat n ipl of hazardous materials covered by the manifest except as noted in I Printed/Typed Signature Month Day Year 1�P�O l 187D(k22 fRev. 3 Q5] PW6ges JTons are obsolete.. 4 ) 00026.1148 DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) 0013 31