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¢ SSL SK SHIP# 227097441 I III�I II II I�II� III VIII �IIII <br /> 006657512SKS <br /> Please print or type. Form Approved.OMB No,2050-0039 <br /> 11*1FORM HAZARDOUS 1.Generator ID Number TX R0000Bt 205 2.Page]!of 3.EmeWW1C'Raspr PJmnc 0 4.Manifest Trackiumber <br /> WASTE MANIFEST 1 OOrrvOrrOO 9btl 1 b 0 0 66`97512 S K S <br /> 5.Generator's Name and Maili Address Generators She Atltlress((if dl8erent Nan mail( atltlress) <br />• SAFETY—KLEEIk� SYSTEMS, INC. SAFETY—L<LEEN SYSTIMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generamrs Phone: 209-545-1011 SALIDA CA 95368 <br /> s.Tr marl 90—Wo) SYSTEMS INC U.S.EPA IO Number TX R00008120` <br />' 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK , CA 94560 <br /> CAD980887418 <br /> 510-795-4400 <br /> Fault"Phorre'. <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Uri 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wi <br /> 1 NON RCRA HAZARDOUS WASTE,LIQUID TT G 133 <br /> a ETHYLENE GLYCOL_ SOLUTION (LESS THAN 50%) <br /> f 2, <br /> W <br /> 3. <br /> C <br /> 14,Special Handling Instructions and Additional Information TSD:EVG `. tal- CSG: <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retained by generator confers aggency authori y <br /> on initial transporter to add or substitute additional trans orters on eneratores behalf. <br /> 15. GENERATOR'StOFFEROR'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, <br /> marked and IabeledlplacaNed,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.h export shipment and I am the Primary <br /> Exporter,I certiry,that the contents of this consignment conform 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)(H I am a large quantity gen or(b)(if am a small quantity generator)is true. <br /> roc's PnntedR Name ignature Monty Day Year <br /> / <br /> MCI <br /> n emotional Shi menuof <br /> p ❑ImpartWU.B. Export horn U.S. Pore levingU.S. <br /> F' Date leaving U.S.. <br /> ?I Transporter signature(far exports only). <br /> ce 17.Transporter Acknowledgment of Receipt of Materials <br /> our <br /> ns 1 PnntedR nature Month Day Year <br /> a <br /> jF rner2Pnntedflype"ame re Month Day Year <br /> K <br /> t18.Discrepancy <br /> 18a.DiscrepancyIndication Space Llpuannty ❑Type ElResidue El Partial El RejectionFull Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA IO Number <br /> J <br /> U <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facllity(or Generator) Monty Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. <br /> 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> 1 Printedrryped Name sign atu e Monty Q y_ <br /> t( <br /> EPAfnf)9� ft62-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />