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-TEXAS CO MISSION ON <br />ENVIRONMENTAL QUAU <br />P.O. Box 13087 <br />Austin, Texbs 78711-3087 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />L <br />I <br />T <br />Y <br />Form Approved. OMB No. 2050-0039. <br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest <br />2. Page 1 Information in the shaded areas <br />WASTE MANIFEST CAD9825-017-36_ <br />Of 1 is not required by Federal law. <br />I <br />3. Generator's Name anij ME�Iin��kd�rrs <br />A. State Manifest Document Number <br />6 0:3 <br />S 01228638 <br />STOCKTON CA 95206 <br />B. State Generators ID <br />4. Generator's Phone ( 209 ) 27 4-6 8 3 4 <br />D0006 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID 8 7 10 9 <br />D. Transporter's Phone 800 669-5740 <br />SAFETY-KLEEN SYSTEMS, INC TXR000050930 <br />7. sporter 2 Company Nam 8. US EPA ID Number <br />y7 <br />E. State Transporters ID <br />Z, kx&ov IZZ. 2 -re .7. <br />F. Transporters Phonedq/r- <br />9. Desiqnated Facility Name and Site Address 0 6 to. US EPA ID Number <br />G. State Facility ID <br />SAFETY-KLEEN SYSTEMS. 'INC. <br />65124 <br />1722 COOPER CREEK ROAD <br />H. Facility's Phone <br />DENTON, TX 76208 <br />TXD077603.371. <br />. . <br />940 483-5200 <br />11A. <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, ID <br />12. Containers <br />13'14. <br />1. <br />HM <br />Number and Packing Group) <br />No. Type <br />I <br />Total <br />Quantity <br />Unit <br />Wt/Vol <br />Waste No. <br />a. HAZARDOUS WASTE, SOLID, N.O.S. <br />X <br />(TETRACHLOROETHYLENE, LEAD) <br />DM <br />P <br />DUTS409H <br />9 NA3077 PGIII (ERG4171) <br />b. WASTE SOLIDS CONTAINING FLAMMABLE <br />X <br />LIQUID. N.0 S (GASOLINE, BENZENE) 4.1 <br />iERG#133) <br />DM <br />P <br />fUTS409H <br />UN3175 PG Ii. <br />C. <br />d. <br />OUTS409H <br />K. Handling Codes for Wastes Listed Above <br />�I 5. Special Handling Instructions and Additional Information MFST <br />R/T#106448098 0000-3701-92 <br />EMERGENCY RESP 800--468-1760(24 HR). IF UNDELIVERABLE RETURN TO GENERATOR. <br />SK CORP AUTH'D TO USE SUBSEQUENT CARRIERS: 40343, <br />41038, 81681, 82739. 86256 <br />SKDOT# A: 22373 B; 34273 C; D: <br />16- GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are <br />classified, packed, marked, and labelled/placarded, and are in all respects in proper condition for transport by highway according to applicable international and national <br />government regulations, including applicable state regulations. <br />If I am a large quantity generator, I certify that I have a program in place to reduce the volume and <br />toxicity of waste generated to the degree I have determined to be <br />economically practicable and that I have selected the practicable method of treatment, storage, or <br />Asposal currently available to me which minimizes the present and <br />future threat to human health and the environment; OR, if I am a small quantity generator, I have m <br />e a g ith effort to minimize my waste generation and select <br />the best waste management method that is available to me and that I can afford <br />Printed / TypedSil <br />Month Day Year <br />ELL91 I <br />L. A <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />Date <br />Pri Typed Name <br />Signature <br />Month Day Year <br />-5) <br />�o- <br />18. Transporter 2 Acknowledgement or Receipt of Materials <br />Date <br />Printed :�ignature,,- <br />Day Year <br />Typ <br />_Zme <br />e�dMonth <br />19. Discrepancy Indication Space <br />20. Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in item 19. <br />F Date <br />Printed / Typed Name <br />S, t <br />Signature <br />S,04 <br />Month Day Year <br />169 1--13 1 Cs5 <br />White - original Pink -TSD Facility YeKow-Transporter Green -Generators first copy <br />4 (-19 Y. <br />