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SSL SK SHIP# 227267208 0 0 6 7 7 5 5 5 5 S K 3 Please print or type. form Approved.OMB No.2050-0039 1.Generator ID Number 2.Pae 1 of 3. m R e 4.ManihM TrackingNumber WASTE MANIFEST UNIFORM HAZARDOUS TXR@@@@812@5 g 1 — ��— @ 1006775555 SKS 5 G ea tl A e Generators Site Address if different than maili address) §hf&PAt� �� 9%TEMS, INC. SAFETY— LEEN SYST MS, INC. PO BOX 555 5050 SALIDA BLVD SALIDA CA 95368 Generators Phone: 209-545-1011 SALIDA CA 95368 6.T%WtfgoW'EP N SYSTEMS INC U.S.EPA ID Number TXR000081205 7.Transporter Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA U.S.EPA ID Number 6880 SMITH AVE. NEWARK , CA 94560 CAD980887418 510-795-4400 Facility's Phone. an. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity 13.Waste Codes Ali NON RCRA HAZARDOUS WASTE,LIOUID TT G 133 o ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) da � L90 Z 2. w 3. 4. 14.Special Handling Instructions and Additional Information TSD:EVG SRL CSG: I 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retained by generator confers ag9ency authari y on initial transporter to add or substitute additional trans Drters on eneratores behalf. 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 are 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 consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantlty generator)or(b)(if I am a small qd^generator)is true. Generator'slOfferoes Pnnted7yped Name Signature Month Day Year 1)•41/ L T 2- 12-7i 16 International Shipments F ❑Import to U.S. ❑Export from U.S. Port of enbylexiC ? Transporter signature(for exports only): Date leaving U.S.: Lid 17.Transporter Acknowledgment of Receipt of Materials 1i Transporter 1 Pnnted7Typed Name Signature Month Day Year L/9� aM ( Z 2 /9- Z Transporter Printed/Typed Name Signature Month Day Year r 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantic ❑Type ❑Residue Quantity yp [:1 Partial Rejection ❑Full Rejection Manifest Reference Number: r 18b.Alternate Faculty(or Generator) U.S.EPA ID Number J U LL Facility's Phone. W 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) o 1 2. 3. 4, 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as note in Item 18a Pnmed/Typed Name �(x _�fG Signature Month Day Year YV EPI Piy�1�3�v3�- 1) Previous editio Pare obsolete. I VS10NATED FACILITY TO EPA's e- ANIFEST YSnnA