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SSL SK SHIP# 226929441 I�IIIIII�IIIIIII��'l1II�I1I�IIINII� <br /> 0067760713 KS <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNItORM HAZARDOUS 1.Generator ID Number TX R000081205 1 <br /> 2'Pagel of 3.Eme910 ReWUr PJtufp.0 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 11 B tl1OrrO0 CC 1 1 6 6 1006776071 SKS <br /> 5.Generators Name and Mailin Adtlress Generators Site Address((i fdiRerenttiianmaili address) <br /> SAFETY—KL SYSTEMS, INC. SAFETY—f(LEEN SYS%MS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 2209-545-1011 SALIDA CA 95368 <br /> 6.Trigh f(C_Tx'fpatyft SYSTEMS INC U.S.EPA ID Number TXROOOOB1205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, INC. U.S.EPA ID Number <br /> 6000 88TH STREET <br /> a SACRAMENTO , CA 95828 CA0000084517 <br /> 916-386-413 ' <br /> Faahys Phone: <br /> 9a. 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers it.Total 12.Unit 13.Waste Codes , <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> Ni <br /> 0 (A <br /> Z z. NON—RCRA HAZARDOUS WASTE, LIQUID DM G 134 <br /> uJ <br /> (AQUEOUS PARTS WASHER SOLUTION)RGRA HAZARDQW6 ACTIT I T17111 I E—411iL- <br /> V <br /> _ (RQ <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:SCA SAL 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 enerator' s behalf. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> 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 l am the Primary <br /> Exporter,I cenify,that the contents of this consignment conform to the tens of the attached EPA Acknowledgment of Consent. <br /> I codify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(01 am a small quantity generator)is true. <br /> G ratorslofferors Print Ry d Name Signatu Month Day Year <br /> S <br /> 16.International Shipments <br /> F, El import to U.S. Export from LLS. Pon of entrylexiC <br /> 91 Transporter signature(for exports only): Date leaving U.S.: <br /> C 17.Transporter Acknowledgment of Receipt of Matenes <br /> 1- Month r 1 Pdntedrryped me S a M1ot^ Da Year <br /> aAAP <br /> `Y 1 <br /> W T2nsporter 2 Prints dlfy me Signature Month Day Ye <br /> F e..1s ► 1111 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity F-1 Type ERe due ❑Partial RejectionI <br /> ❑Pati Reaction <br /> Mai Reference Number: <br /> r 18b Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone'. <br /> ILL! 18c.Signature of Alternate Facility(or Generator, Month Day Year <br /> Q <br /> Z <br /> h19.Hazardous Waste Rated Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. H141 s. µ»7j 4. <br /> as <br /> 20.Designated Facility Owner or Operator'.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> ad Name alure Month Day <br /> d7f y ear <br /> FP -1 P,(evi U ilonIa�nhsp�ete. » DESIGNATED FACILITY 0 EPA's e-MANIFEST SYSTEM <br /> C 1 147 1 1 brD 3 /fin.. <br />