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z 11101111111 MEMO oil 11111111 0 0 7 1 5 6 6 8 1 SKS Plasm pdnt or type. Found Approved.OMB No.2050-0039 1.Generator ID Number 2.Page 1 of 3.E Res n UNIFORM HAZARDOUS r.�e Phone 14.Manifest TraCilfing Number WASTE MANIFEST I a I 17r 007158681 SKS 5.Generators Name and Mailing Address Generators She Address(if different than mailing address) 1 p T -!77 W Vo 3, t a As . ,M A M T EC r, `0Q-,7t4'-, 91,, CA 3 '7-9f,µ1 Generators Phone: 6.Trp U.S.EPA ID Number�VT — " Vr qyq-C-mq 7.Transporter 2 Company Name U.S.EPA ID Number CLF^M HARB1OT✓'7 F`NV SUC T.NF. M A DO 3 9 2 2 R 5 4") 8.Designated Facility Name and Site Address FAFETY-KLEEN RYSTFIVIS, TV7, U.S.EPA ID Number 6000 88TH STREET SACRAMEMTQ I M i 7 CA Facilitys Phone: 9,. go.U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Padding Group�if any)) No. Type Quantity WL/V01. 13.Waste Codes 1. NnN-PCQA HA-PPT,) 'I G �CUS WA-m-r, LIFI! llnl TT 0 IIIA` G, -LUMGF� z 4 3. 4. 14.Special Handling Instructions and Additional Information aH EMERGFr -p—! by '. 7t - jSiIL S �6o? F- V F: i C*' 3 .: st ute a,11,t t� a�i:;r -t nw1 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and am classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this coollignment conform to the terms of the attached EPA Acknowledgment of Consent- I cedify that the waste minimization statement idenfified in 40 CFR 262.27(a)(K I am a large quantity generator)or(b)(if I am a small quantity generator)is We. GeneratoeslOffeene's P nted/Typed Name Signature Month Day Year I " otr-c�— 16.International Shipments 1:1 Import to U.S. ❑Export from Pad of entrymoat Transporter signature,(for exports only): Date leaving U.S.: WX 17.Transporter Admaidedgment of Receipt of Materials — t2 Tra der 1 PdntDdffyped Name Sig ra Month Day Year Iq0 Z Transporter 2 PjnLdffyped Name Signature I Month Day Year El 18 DiscrepancyDiscrepancy18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection E]Full Rejection I Manifest Reference,Number 18b.Ntemate Facility(or Generator) U.S.EPA ID Number :3 E3 I Facilitys Phone: W 18c.Signature of Alternate Facility(or Generator) —TNMVR�tt Year 19.Hazardous Waste ReW Management Method Codes(i.e.,codes for hazardous waste Vestment,disposal,and recycling systems) 1, 3. 4. 20.Designated Facility Omer or Operator.Certification of receipt of hazardous materials covered by the man=t as noted in Item 18a /-5Mon ay r T)4V— -t* ADX EPA Form ftq-22 JRev.12-17) Previous edifions are obsolete. DESIGNATED FACILITY TO EMS e-MANIFEST SYSTAM