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a -LSSA. _ <br />Piease orint or tvoe. (Form designed for use nn mita 119_nifr hALmrcr t �► _ .. _ _ _ _ _ _ _ _j <br />EPA <br />cVaV-wJu <br />1. Generator ID Number CAD 2. Pae 1 of 3. Emer enc Response Phone 4. Manifest Trackin Number <br />UNIFORM HAZARDOUS g 9 Y P g <br />WASTE MANIFEST 11-600-468-1760 '002108268 SMS <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />CAL, TRANS DIVISION 10 CAL TRAMS DIST IQ <br />1603 S S ST 1603 S S ST <br />ST .CKTON CA 75496.. P DIVISION <br />Generators Phone: t � 45" Sl STOCKTO A 75205" <br />6 #e WPP m r T a INC. U.S. EPA ID Number TXR000 5073 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address SAFET'S°-°t LEEN SYSTEMS, INC.0007,60 ., U.S. EPA ID Number <br />6004 88TH STREET <br />SACRAMENTO CA 75828 <br />716-386-��4715 D4� 8451 <br />Facility's Phone: <br />ga, <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 />Quant' riY <br />Wt./Vol.­ <br />= 13. Waste Codes <br />No. <br />T <br />Type <br />.X <br />"HAZARD"OUS S E, LIQUID, N.O.S. <br />or <br />6 <br />D037-134 <br />7 NA3082 PS III (DO7) <br />w <br />LU <br />2 4ON-RCA HAZARDOUS WASTES LIQUID <br />S <br />134 <br />(AQUEOUS IMMERSION CLEANER) <br />$ � <br />t�6 <br />3NOW—RCRA € AZARDDLIS WASTE, LIQUID <br />DM <br />134 <br />(AQUEOUS PARTS WASHER SOLUTION) <br />4. <br />14. Special Handling Instructions and Additional Informationr <br />S TRIS#x,10560755 0037777705 0000370172 0735 E <br />I)E#171 <br />S'AUTINDRIZED TOET I. ,L I EES SE E T CARRIERS S IEE E S> <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately des cribed.above by the proper shipping name, and are classified, packaged, <br />marked and labeled/ lacarded, and are in all respects in roper condition for transport according to a applicable international and national ovemmental re ulations.;If ex ort shi Ment and I am the Primary <br />P P P P P 9 P!? g g p, p <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowled9 meat of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) if quantity I am a large ( g q ty generator) or(b) (if I am a small quantity generator) is true. <br />Generator's/Offeror's Pnnted/Typed Name Signature Month Day Year <br />--r <br />F— <br />16. International Shipments ❑ Import to U.S. m El Export from U.S. ` Port <br />z <br />of entry/exit <br />Transporter signature for exports only): P 9 � P Y): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />OTransporter <br />1 Printed/Typed Name gg Signature Month D$ay Yegaarr, <br />11) <br />Q <br />Transposer 2 Printed/Typed Name Signature t, ` "` " Month Dayl, Year <br />t- <br />18. Discrepancy <br />18a. Discrepancy Indicztion space �" � Quantity LJ Type q <br />❑ Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />J <br />U.S. EPA ID Number <br />U <br />W <br />Facility's Phone: <br />Uj <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />!7c <br />Z <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />UJ 1.. <br />i11 <br />2. II: <br />3."5 <br />14. <br />20. <br />Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Pri"ntedlTyped Name -Signature-r Month. Day ° r Year <br />lkw <br />For 8nb-22 (Rev 3-01W `Previous editions are obsolete' <br />1 x S } €14311 3) 0014741 DESIGNATED FAGILITYTO GENEWOR <br />