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SSL SK SHIP# 227550353 IIIIIII (I IIII�IIIIIIIIIIIIIIIIIII <br /> 0 0 6 9 5 2 7 8 9 S K S <br /> Please print or type. Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page_i of 3.Emesv R�s�o�se 4.Manifest Tracking Number <br /> WASTE MANIFEST TX R000081205 1-drar -'M -Mo 100695278 n SKS <br /> 5.Generator's Name and Mailing Address Generators Site Addrese if ddferent than mailing address! a71��7 <br /> SAFETY-KLEEN SYSTEMS, INC. SAFETY-KLEEN SYST6 -• <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209-545-1011 SALIDA <br /> 6Tr9Wi `LM L SYSTEMS INC U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. <br /> 8.Designated Facility Name and Site Address THERMO FLUIDS INC U.S.EPA ID Number <br /> 12533 SE CARPENTER DR <br /> Facility's Phone: CLACKAMAS , OR 97015-8988 <br /> 503-788-4fi16 0RG!0000?.,197 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(it any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> 1. NON-RCRA HAZARDOUS WASTE SOLIDX23 <br /> o (DRAINED/UNDRAINED USED bIL FILTERS) <br /> �9 o <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD;TPO <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract retained by generator r_orl arenr_y crit I' - <br /> 1 ns •t s on •a is b aIf, <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 new,aid are classified,packaged, <br /> marked and Iabeledlplararded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.N export shipment and I am the Primary <br /> Exporter,I cerdly that the contents of this consignment cenform 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)if I am a large quantity generator)or(b)(if I am uai generator)is We. <br /> G retoes/Ofie es Printed Nartre SignaNre Month Day Year <br /> �t'�,y�,. b`a i <br /> 16.International Shipments <br /> F ❑Import to U.S. ❑Export U.S. Pod of entry/exit <br /> ? Transporter signature(for exports only). Date leaving U.S.: <br /> W 17.Transport&Acknavledgment of Receipt of Materials <br /> IJJ <br /> K Trnansp�orter1 Pnmed/Typed me Signet Month Day Year <br /> y' 1, «, (4i bd I a <br /> r 2 Pjv;dajT^pped Name Sign Month Day Year <br /> y * 18.Discrepancy <br /> I I 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type EJ Type ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ua- Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> y19.Hazardous Waste Report Management Method Coles lids.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � 1. h8l 2. 3. 4. <br /> 1 20 Designated Facility 01 or operator:Cemfi at on of receipt of hazardous materials overed by Che man fest except as n ed in Item 18a <br /> Pdntedrryped Name Signature Month Day Year <br /> :TA , .• � Z zs 1 <br /> EPA Form 8700-221Rev.12-17) Pre ous editions are obsolete QESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 1)7872676/1560,33 <br />