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.TE XAS 1COMMISSION ON <br />ENVIRONMENTAL QUALITY <br />P.O. Box 13087 <br />Austin, Tetas 78711-3087 <br />oj-- ;,4 — tlm. 11:— el—innori fnr i mo nn elite (I P-nitnh) tvnpwritpr.) <br />40 Form Approved. OMB No. 2050-0039. <br />TCEII)V 1" V­ <br />LR#V.OA1516?) 09'1 O-ZQQ 0 3 4 <br />1-- � ^ � A .......... <br />UNIFORM HAZARDOUS 1. Generators US EPA ID No. Manifest <br />2. Page 1 Information in the shaded areas <br />WASTE MANIFEST . * r . . . I — - <br />I of is not required by Federal law. <br />3. Generator's Name and Mailing Address CAL TRANS DIVISION 10 <br />Z'K 51 <br />1603 S B ST <br />M 4`411 <br />STOCKTON CA 95206 <br />4. Generator's Phone 209 274-6834 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />SAFETY-KLEEN SYSTEMS, INC TXR000050930 <br />7. Transporter me 8.PAI <br />WAR—F <br />.9---Mly <br />9. Designated Facility Name and Site Address 000618 10. US EPA ID Number <br />wis. <br />W� <br />SAFETY-KLEEN SYSTEMS, INC. <br />1ill -s-111 <br />1722 COOPER CREEK ROAD <br />DENTON, TX 76208 <br />M, <br />TYD07.7ra033.71 <br />11A. 11. US DOT Description (including Proper Shipping Name, Hazard Class, ID 12. Containers 13. 14. e` j, <br />Total Unit <br />No. Type <br />HM Number and Packing Group) <br />Quantity Wt/Vol <br />IF <br />a. <br />HAZARDOUS WASTE, SOLID, N.O.S. <br />DM P <br />I <br />P!% " - <br />G <br />TETRACHLOROETHYLENE, LEAD) <br />I'll <br />E <br />NA3077 PGIII (ERG 171` <br />b. <br />E <br />R <br />A <br />NYt;Nt; 2171 <br />F <br />T <br />O. <br />R <br />C. <br />d. <br />& <br />41" <br />2 <br />4—ARE RE <br />15 Special Handling Instructions and Additional Information <br />MFST R/T#105942400 <br />0000-3701-92 <br />EMERGENCY RESP 800-468-1760(24 HR). IF UNDELIVERABLE <br />RETURN TO GENERATOR. <br />SK CORP AUTH'D TO USE SUBSEQUENT CARRIERS: 40343,41038,81681,82739,86256 <br />SKDOT#-A: 22373 B: 3"4-27-30iC: 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 toxicity of <br />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 disposal 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 made a good faith effort to minimize my waste generation and select <br />the best waste F anagement method that is available to me and that I can afford. <br />Prin S&4alfe <br />Month Day Year <br />co .91 e .-a le -r <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />Date <br />R <br />A <br />Pr dType Name am <br />Signature <br />Month Day Year <br />N <br />AJUA4"Al <br />P <br />0 <br />AQ. Transporter 2 Acknowledge femkor Receipt of Materials <br />Date <br />R <br />T <br />'\ P;rikted / Te!Tame <br />'N <br />Signature <br />0 <br />�D tarE <br />R <br />I <br />19. Disic�reancy Indication Space <br />F <br />11 <br />- <br />20. Facility Owner or Operator: Certification of receipt of hazardous materials covered by this man' et as noted in item 19. <br />T <br />F <br />Y <br />--Pate <br />Printed / Typed Name <br />Sig—nature <br />TCEII)V 1" V­ <br />LR#V.OA1516?) 09'1 O-ZQQ 0 3 4 <br />1-- � ^ � A .......... <br />