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lease print or type. (Form designed for use on elite (12-pitc writer.) Form Approved. OMB No. 2050-0039 <br />1. Generator ID Number 2. Pae 1 of 3. Emergency Response Phone 4. Manifest Tracking NCAMEumber <br />UNIFORM HAZARDOUS . Page 9 Y P 9 . . <br />WASTE MANIFEST I 0-469-1760002 <br />5. Generator's Name and Mailing AddressGenerator's Site Address (if different than mailing address) <br />CAS. TRANSI T I N Ind CAL TRANS DIST 10 <br />1603 T 1603 5 V ST <br />STOCK€_ N CA 05206 EQUIP DIVISION <br />Generator's Phone: 2* -- —7813 STOCKTON <br />CA 9MV05 <br />6.Trans orter 1 Compan Name U.S. EPA ID NumbARer <br />A TS'@-MLER T , INC. <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address SAFETY—KLEEN INC 760 U.S. EPA ID Number i <br />6060 BOTH TR 9T .i <br />,. <br />SACRAMENTO <br />..:pgpg,.. .+.p <br />366-4713 <br />yr. yg�./gg�_g �l..: <br />+� <br />Facility's Phone: <br />9a, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />1-HAZA OUS WASTE., LIQUID, N.G.S. <br />DF <br />G <br />D039134 <br />o <br />7 NA30ez pis III (M <br />z <br />2.Nt__R RA HAZARDOUS QA T , LIQUID <br />6 <br />134 <br />(AQUEOUS 1MMERSION CLEANER) <br />34" A HAZARDOUS UASTE, ILII' <br />S <br />134 <br />( UE OU PARTS UASHER SOLUTION) <br />4. <br />14. Special Handling Instructions and Additional Information TIRCKNIX0715466 0037416152 0000257017207310 Z4 <br />rer )ERE#1 1 <br />..q,. <br />SK AUTHORIZED TO RETAIN LXENSED.SUBSEQUENT CARRZERS AS NECESSARY <br />15. GENERATOR'S/OFFEROR'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 labeled/placarded, and are in all respects in proper condition for transportaccording to applicable1ritemational and national governmental regulations. If export shipment and I 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 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a targe quantity generator) or(b) (if I;am a small quantity generator) is true. <br />Generators/OfferorsPhnt d/T eo'•Name Signature <br />r <br />oi <br />Man Day Year . <br />-� <br />�— <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. TransporterAi;knoWedgment of Receipt of Materials <br />O <br />a". <br />Transporter 1 Printed yped Name Stature JOQ'tt7) <br />61 <br />Ign D Year <br />QTransporter <br />.. <br />2 Printed/Typed Name -' Signa ure <br />Month Day Year' <br />r <br />. <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Qua nti ty ❑Type ❑Residue E] Partial Rejection <br />El Full Rejection <br />Manifest Reference. Number. <br />18b. Alternate Facility (or Generator) <br />J <br />U.S. EPA ID Number t - <br />V <br />L <br />Facility's Phone: <br />w <br />Q <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Z <br />H <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />UJ <br />1. <br />iit s <br />2. <br />H14120. <br />3..,:: <br />4. <br />Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as reed intern 18a <br />Printed/Typed ame 'r <br />a Sig a � ,�� % ,% <br />Month Day Year <br />EPA Foryrmp�d,87042yg2 (Rev. 3-05) Previous editiogns are <br />yobssole`t�e. gF DESIGNATED FACILiTYTO GEIVER&OR <br />