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,...7142 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM yAZARDOUS 1.Generator ID Number 2.Pa 1 of E cy s Manifest Tracking Number <br /> CAL00019s294 � �- �" I,. <br /> 002844360 SKS <br /> •= WASTE AJ(ANIFEST <br /> s' .Gen ator's Na a and Me Address Generator's Site Address(if different than mailing address) <br /> STOCKT0�1 RUB ER MFG CO INC <br /> 5023 N FLOOD RD EARL WILSON <br /> LINDEN CA 95236 <br /> ' Generator's Phone: 209 887-1172 <br /> 1. � T� eSYSTEMS, INC. U.S.EPA ID Number TXR000050930 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and'Stte Address SAFETY--KLEEN SYSTEMS, INC. U 111D Number <br /> 6000 88TH STREET <br /> SACRAMENTO , 'CA 95828 <br /> 916-386-4913 CA0000084527 <br /> Facility's Phone: <br /> ga. 9b.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 Wt.Noi. <br /> a X 1-WASTE PAINT RELATED MATERIAL93, UN1263, DM P F'003 D001 D@ig <br /> o PG II, <br /> D035 D039 12 <br /> a 2. <br /> w <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information SK SHIP#204133159 54121655 2988000 CSG: <br /> 1)ERG#128^ <br /> 24'iiR EMERGENCY #1-800-468-1760 (SAFETY--KLEEN - CONTRACT #94138) <br /> SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 15. GENERATOR'SfOFFEROR'S CER71FICATI()N: i hereby declare that the contents of this consignment are fully and accurst*described above by the proper shipping name,anxt are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport,aMnling to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this c6nsignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)Of I am a large quantity,generator)or(b)Of i am a small quantity generator)is true. <br /> Ge eretoeslOfferoes Printed/Typed Name Signature Month Day Year <br /> ! --�0 J r.1 2 Zr. <br /> 16.1riftelf6rialShipments <br /> z ,. 1:1 Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature,for exports only): Date leaving U.S.: <br /> w 17.Transporter,Acknowled ent of Receipt of Materials <br /> Transpor�tor 1 Printed1Typ me Signature Month Day Year <br /> O <br /> CL <br /> co <br /> Tran pbrter Z!Printe!Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue j ❑Full Re <br /> ❑Partial Rejection Jection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 0 19.Hazardous Waste Report Management Method Codes(i.s.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 188 <br /> PrintedlTyped NjRe Signature Month Day Year <br /> ---�--- d/ f 1 S- / <br /> ETA)F1or01.$zf liW4M) Previous i sare otWee. DESIGNATED FA YTO GE ERATOR STATE(IF REQUI ED), <br /> lbw b <br />