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- 14. Special Handling Instructions and Additional Information SK TKC91t,X10788135.003TS975750734 I)ERGfI71e - r Please print or type: (Form designed for use on elite (12 -pit writer.) . Form Approved. OMB No. 2050-0039 ` 1: Generator ID Number 2 -,Pae 1 of, 3. Emergency Response Phone UNIFORM HAZARDOUS ; 9 r9 cy P 4. Manifest Trackin ' Number g' SK AUTHaRIZED-TOT I LICENSED SUBSEQUENT CARRIERS AS NECESSARY WASTE MANIFEST I $-500-68w1 SKS —002090198 5. Generator's Name and Mailin Address C TRANS 10 Generator's Site Address (if different than mailing address) CAL TRANS DIST 10 1603, S' IS ST STC.6 CA 75206 EQUIP DIVISION I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator's Phone: SaTSI TO CA 75205 Generators/ ernes Printed/Typ d Name Signaturf 01 ( t � ` Month Day Yea € 'AffleV422"emarntYSTEMS, INC. U.S. EPA ID Number TXR00005030 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: f 7. Transporter 2 Company Name U.S. EPA ID Number - -- -- 8: Designated Facility Name and Site AddressSAFETJ—KLEEN SYSTEMS, INC. 000760 U.S. EPA ID Number Cl) 6000 STREET— TREET;.S Mont D Year a Transporter 2 Pnmed/ Typed Name Si ure .STH SACRAMENTO CR E TO CA IPSS28 Month Day Year tY _ 18. Discrepancy Facility's Phoney 18a.Disc�e�anc li�oiaation'S ane" '' t—� _4.- . Quantity LJ Type Residue - 0 Partial Rejection 1 .. 0 FuII Rejection 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit J U Lj- Facility's Phone: HM and Packing Group (if any)) H18c. Quantity Wt./Vol. 13. Waste Codes No. Type Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) " 'HAZARDOUS WASTE, LIQUID, 14.10. S. 0 1. K41 DF 3. K141 S D03? 134 0 mson Pe III mom 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a , Printed/T pad Name Signature / ' f Mo thDay Year EP or"m 870 7 (F v. 3-05�) Previous editions ar obsolete. DESIGNATED FACILITY TO GENERATOR 2 C- C A HAZARDOUS WASTE, LIQUIDM 6 134 CM CAOUEOUS IMMERSION CLQ.) 3 ON - C HAZARDOUS STT,LIQUIDDM a 13 ;AQUEOUS PARTS UASKIER SOLUTION) ) 4. - 14. Special Handling Instructions and Additional Information SK TKC91t,X10788135.003TS975750734 I)ERGfI71e _ 24 SK AUTHaRIZED-TOT I LICENSED SUBSEQUENT CARRIERS AS NECESSARY 15. GENERATOR'S/OFFEROR'S CERTIFICATION: thereby declare that the contents of.this consignment are fully and accurately described above by the propershipping name; and are classifed,%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 EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generators/ ernes Printed/Typ d Name Signaturf 01 ( t � ` Month Day Yea € J i— z, 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: f Transporter si ature, for exports only): Date leaving U.S.: w 1 sporterAckn wl dgment of Receipt of Materials Cl) Transporter 1 Printe Wiped Name f S, nature ,/ Mont D Year a Transporter 2 Pnmed/ Typed Name Si ure Month Day Year tY _ 18. Discrepancy 18a.Disc�e�anc li�oiaation'S ane" '' t—� _4.- . Quantity LJ Type Residue - 0 Partial Rejection 1 .. 0 FuII Rejection Manifest Reference Number: 18b. Altemate Facility (or Generator) U.S. EPA ID Number J U Lj- Facility's Phone: H18c. Signature of Alternate Facility (or Generator) - Month Day Year z w19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) " 0 1. K41 2. I I 3. K141 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a , Printed/T pad Name Signature / ' f Mo thDay Year EP or"m 870 7 (F v. 3-05�) Previous editions ar obsolete. DESIGNATED FACILITY TO GENERATOR