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SSL SK SHIP# 229223497 u IINIIh111HIiN1millimmill <br /> 0071565173 K8 <br /> Please print or type. Form Approved.OMB No.205MO39 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Erne en Response Phone 0.ManiPosl Tracking Number <br /> WASTE MANIFEST T X R000081205 1 1-�30 -468-1760 0 0 7158517 SKS <br /> 5.Generatofa Name and Mailing Address Generators Site Address(dtlifferent than mailing address) <br /> SAFETY-KLEEN SYSTEMS, INC. SAFETY-KLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209-545-1011 SALIDA CA 95368 <br /> 6.Tmn ref 1 Com any,Name U.S.EPA ID Number <br /> SnFETY (LEEN SYSTEMS INC TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated FaalityNam and Site Address SAFETY-KLEEN OF CALIFORNIA U.S.EPAIDNumli <br /> 6880 SMITH AVE. <br /> NEWARK , CA 94560 <br /> 510-795-4400 CRD980887418 <br /> Facllitys Phase: <br /> 9a. St.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unci <br /> HM and Packing Group(d ano. Type Quantity W 13.Waste Codes <br /> y)) NLNOI. <br /> at NON RCRA HAZARDOUS WASTE,LIQUID TT G 133 <br /> 0 ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) <br /> ao � Zoo <br /> z T. <br /> W <br /> t7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:EVG SAL CSG: ` <br /> 24H EMEP,GENCY#800-468-1760-CH/SK/TFI-Contract retained by generator confers a ency authors y <br /> on initial transporter ' <br /> 15. GENERATOR'SIOFFEROR'S CERnFICATION: I hereby declare that the contents of this consignment are fully end accurately described above by the proper shipping new,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper cendifion for transport according to applicable international and femoral governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform re the terms of the attached EPAAcknowledgment of Con <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x)(ti l am a large quantity generator)or(b)If I a sural uant ty generator)is true. <br /> Generators/ rs PrinredR ped Naaw- Signature Monty Day Year <br /> Willi 100111119 <br /> F 16.HIST011off Shipments ❑Import to U.S. ❑Export from U.S. of enbylexit <br /> ? Transporter signature(for exports only): ate 1 .5.: <br /> W 17.Tra sporterAdmowledgment of Receipt of Materials <br /> Transporter rinbaCyped Name Signalure Month Day Year <br /> 0 <br /> Z Traffilli 2 PnnLNVTyped Name Signature Math Day Year <br /> 9 r <br /> 4. 18.Discrepancy <br /> 18a.Discrepancy Indication Space El ❑Type ElResidue ❑Partial Raj.%. E]FullRejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility for Generator) U.S.EPA ID Number <br /> J <br /> U <br /> W Facllil)•s Phone: <br /> Maj 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> zz <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> z6 1 G 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:C rtificamon of receipt of hazardous materials covered by the mans z pt as noted in Item Ise <br /> PrintedRyPed Name S' a M Day <br /> EPArm 87 0- R .12-17) Previous edrbons are obsol . DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 1. 651/i- 30 <br />