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.. .. .... . . <br /> ire SSL sr, GNIF'# 227431239 HIM 11111111111111111111111111111 <br /> 0 0 6 7 7 6 6 4 4 S K 3 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Pag 1 of 3. m R e 4.Manifest Tra`77 <br /> Id Number <br /> UNIFORM HAZARDOUS TX RID000B 1205 e1 —$ � '0 p p 6 7�(6 6 4 4 SKS <br /> WASTE MANIFEST <br /> 5.Ge� etl A Generagrg SitgAYoSKLEENt� YITt Mess) INC. <br /> (r� . i0jR'0�TEMS, INC. 1HFF <br /> PO BOX 555 5050 SAL.IDA BLVD <br /> SALIDA CA 95368 <br /> 209-545-1011 SALIDA CA 95368 <br /> Generator's Phone: <br /> 6.TrigffF ljog"n er SYSTEMS INC U.S.EPA ID Number TXROOOOB1205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY-KL.EEN OF CALIFORNIA U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK , CA 94560 <br /> 510-?95-4400 CAD980887418 <br /> Facility------ <br /> 9 <br /> 9a 9b.U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WLNol. <br /> NON RCRA HAZARDOUS WASTE,LI�UID TT } <br /> 33 <br /> ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) <br /> 7ilJ`— <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 7—Special Handling Instructions and Additional Information TBD: --VG SAL CSG: 1 <br /> '4H EMERGENCY#800-468-1760-CH/SK/TFI-Cont'r•act retainer) by generator, confar=. agency authori , <br /> On initial t±ansparter to add or substitute additional transporters on enerator' s behalf. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare Nat the contents of this consignment are fully and accurately described above by the proper shipping name,am are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am Ne Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Cons t. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(if l a-mal uantity generator)is W e. Month Day Year <br /> Generator' Iferors Printedi ped Name Signature <br /> Li oZ.IL8 1 <br /> 16.International Shipments Import to U.S. ❑Export from U.S. of entry/exit <br /> F Date leaving <br /> ? Transporter signature(for exports only) <br /> W-Ulu17.TransporterAcknoavedgment of Receipt of Materials Month Day Year <br /> Transporter Printedffyped Name Signature OZ. g L <br /> O <br /> a Month Day Year <br /> Z Transp her2 Prinsall typed Name Signature <br /> K <br /> r <br /> ,S 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> J <br /> U <br /> LL Facty's Phone: Month Day Year <br /> W 18c.Signatureof Alternate Facility(or Generator) <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes do codes for hazardous waste treatment,disposal,and recycling systems) 4 <br /> W 1 2 3. <br /> 1 L-1 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the m at ex t as noted in Item 183 Month Day Year <br /> Prin ed Name ]" <br /> EP 7110- M2-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />