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SSL SK SHIP#k3/0001/01 11111111111 milt I 111111111 <br /> 0072766145K8 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Eme enc Res nse Phone 4.Manlfesf Tracking Number <br /> WASTE MANIFEST TY:Ra20•_, 5 1 CA9-48-176 072 SKS <br /> 5,Generators Name and Mailing Address Generators Site Address(d different than mailing address) SKS <br /> VV <br /> SAFETY-KLEEN SYSTEMS, INC. SAFETY-KLEEN SYSTEMS, INC. <br /> PO ROK 555 5050 SAE.IDA 81._VG <br /> SAI-JDA CA 9536B <br /> Generators Phone: <br /> 209-545-10"1 1raAE If}Cs CA 45368 <br /> 6,Tran I 1 Com any Name Q.S.EPA ID Number <br /> OFETY r- Et4 SYSTEMS. T NC TX Rir'IH,00811 220 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS EN+J SVC INC. MAD@39322250 <br /> 8.Designated Facility Name and Site Address THERMO FLUIDS INC U.S.EPA ID Number <br /> 1�-'S33 SE CgRPE:NTFK DR <br /> (_ACE AMAS , OR 9701.5—AWS <br /> uf'1 _-7?�i�i'-'=i'C�[Fi I_:RC!�•�I�i�irZ1�.,J1='!7 <br /> Facility's Phone; <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity M.Nol. <br /> 1 NON-RCRA HAZARDOUS WASTE, SOLID � DM -7W) P r" <br /> 0 (DRAINFDIUNLIRAINED !ISED U11. FILTERS) <br /> z z. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD e TPO CRL CS ry 7 <br /> 24H EMERGENCY#t? .-u5?3—??Cid—i: ,'Sl iTFI—rnnir .€t relaine� ay gener�at-or canfer-s a envy a:Ithar• •y <br /> m - '11- -r €:i-ss r c,t <br /> 15. GENERATOR'SIOFFEROR'S CE IFICATION.I hereby decare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, } <br /> marked and labeledlplacarded,and are in all rospects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and t am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I oerfify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)' m a small quanfity generator)is true. <br /> G r'slOffami's PdpWyped <br /> ^^Naanme Signature Monlh Day /Year <br /> 3Vv <br /> J 16.Internationj Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Podo ntrylexit <br /> M Transportersignature(fur exports only); ate ving U.S. <br /> X 17.Transporter Acknowledgment of Ramipt of Materials <br /> Tran r 1 PdntedlTyp ame Signature Month Day Year <br /> ov�/�`E� � f o2 7 <br /> CIL. I 00--k <br /> 2E Tra sport rin yped Name SgnatureMonth Day Year <br /> /Z Q f <br /> 18.Discrepancy - <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> w Facilityrs Phone: <br /> w 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> t719.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w 1. 2. <br /> O <br /> um <br /> 20.Designate8 Faclity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest excel as noted in Item 18a <br /> PdntedFryped Name Signa re Month Year <br /> EPA Form 87040-22(Rev.12-17)Previous editions are obsolete. D GNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 117P_.7?G,7F. 156' :3 <br /> Page 1 <br />