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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved, OMB No. 2050-0039
<br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Ma ffes Tracking Number
<br />WASTE MANIFEST �. 1-800-468-1760 3329881 F L E
<br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address)
<br />PANCIA-A TRUCKING IN
<br />5000 E: FREMONT Si" DAVE OR DAMS
<br />CA 9521.1-5
<br />Generator's, Phone: KTON 209 943•-Ct00124
<br />6.rans oder ompan Name U.S. EPA ID Number
<br />SA� ETY-�KITEN SYSTEMS, INC. . TYF.r�'br! t?►0cic19G0Z+
<br />7. Transporter 2 Company Name U.S. EPA ID Number
<br />14. Special Handling Instructions and Additional Information ,, a , -. ,/ar �, ^rf ; 07
<br />SK Si, rt__,tw�a/L .q. �g7
<br />211, FIR EMM 1�ICY #1-800-468-1760 (9 FETY-KLEEN 141, 8)
<br />SK AUT11-11D Tf1 iI;E 51-IBSEQ.•)1=NT CAR}*. ERS.41078_ :; .71.81(-381.82739 85399
<br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: thereby declare that the co nsignment 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 transport according to applicable international 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 EPA Acknowledgment of Consent.
<br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or b • a small quantity generator) is true.
<br />Generator's/Off, ' PrWed/Typed Name 5reMonth 51 iei
<br />t�Jah�e-
<br />16. International Shipme
<br />Import to U.S. ❑ Export from U.S. Port of entry/exit:
<br />Transporter si ure for exports onl Date leaving U.S.:
<br />17. Trarisood Acknowledqment of Re pt of Materials _ ._._ _. " /ate -1-le
<br />18. Discrepancy
<br />18a. Discrepancy Indication Space Quantity
<br />18b. Alternate Facility (or Generator)
<br />U
<br />Facility's Phone:
<br />w 1Bc. Signature ofAllemate Facility (or Generator)
<br />a
<br />z
<br />❑ Type ❑ Residue
<br />0 Partial Rejection
<br />U.S. EPA ID NumbE
<br />L"
<br />❑ Full Rejection
<br />19. Hazardous Waste Report Management Method Codes (i.e., codes lor hazardous rste treatment, disposal, and recycling systems)
<br />0 1.2. 3. 4.
<br />i
<br />20. Designated Facility 091 or perator: Certficalfon ofreceiRL&a4rdous materials covered by the manifest exce noted in Item
<br />Printedfryped Name Signal nt r
<br />'1904,41 J� 4&::21
<br />EP F rWTA-.2?,@R P v. sedijo arep. so ,j�F�iBr n_ DESiGI�ATED FACILITY T STIN iO1d $TATE (IF REQUIRED) �..,
<br />B. Designated Facility Name and Sae Address SA`(Y_K! FEN SYSTEMS. INC.
<br />1722 C=OOPE'R CREEK ROAD
<br />DEN ONd, TX 76 208
<br />r1y`s%1-•t,g)�_�cay�1;) - _ --- - -- _. TXP��?7G!.'�3 .,.
<br />.,. r � .3i., a
<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 />13. Waste Codes
<br />No.
<br />Type
<br />HM
<br />and Packing Group (if any))
<br />Quantity
<br />Wtivol.
<br />L
<br />0
<br />W
<br />z N OIN Rom-) HPIZA1 DOUS wnSTE SOLID
<br />DM
<br />P
<br />?, 2
<br />T
<br />i,, --
<br />OUTS
<br />(ABSORBENT AND OIL)
<br />�i ,
<br />Zs0
<br />3.
<br />14. Special Handling Instructions and Additional Information ,, a , -. ,/ar �, ^rf ; 07
<br />SK Si, rt__,tw�a/L .q. �g7
<br />211, FIR EMM 1�ICY #1-800-468-1760 (9 FETY-KLEEN 141, 8)
<br />SK AUT11-11D Tf1 iI;E 51-IBSEQ.•)1=NT CAR}*. ERS.41078_ :; .71.81(-381.82739 85399
<br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: thereby declare that the co nsignment 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 transport according to applicable international 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 EPA Acknowledgment of Consent.
<br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or b • a small quantity generator) is true.
<br />Generator's/Off, ' PrWed/Typed Name 5reMonth 51 iei
<br />t�Jah�e-
<br />16. International Shipme
<br />Import to U.S. ❑ Export from U.S. Port of entry/exit:
<br />Transporter si ure for exports onl Date leaving U.S.:
<br />17. Trarisood Acknowledqment of Re pt of Materials _ ._._ _. " /ate -1-le
<br />18. Discrepancy
<br />18a. Discrepancy Indication Space Quantity
<br />18b. Alternate Facility (or Generator)
<br />U
<br />Facility's Phone:
<br />w 1Bc. Signature ofAllemate Facility (or Generator)
<br />a
<br />z
<br />❑ Type ❑ Residue
<br />0 Partial Rejection
<br />U.S. EPA ID NumbE
<br />L"
<br />❑ Full Rejection
<br />19. Hazardous Waste Report Management Method Codes (i.e., codes lor hazardous rste treatment, disposal, and recycling systems)
<br />0 1.2. 3. 4.
<br />i
<br />20. Designated Facility 091 or perator: Certficalfon ofreceiRL&a4rdous materials covered by the manifest exce noted in Item
<br />Printedfryped Name Signal nt r
<br />'1904,41 J� 4&::21
<br />EP F rWTA-.2?,@R P v. sedijo arep. so ,j�F�iBr n_ DESiGI�ATED FACILITY T STIN iO1d $TATE (IF REQUIRED) �..,
<br />
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