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SSL SK SHIP# 228532672 <br /> 0 0 6 9 6 1 4 3 a $ K 5 <br /> Pleasa print or Form Approved.CMB No.2D50-U0.39 <br /> l3NIF0ANI HA7ARp0{J$ '.Ga memrlD Nantax CAT>i 0961356P 2 Page�of 7. ►' j 0 1.Ifart1w iradsngmum6w <br /> WASTE hMWFEST 1006961438 SKS <br /> 5.Generak t Name and Miskng AddrMss C,eryramrs Ste Adoress(Rd111aan dlad Mad"address! <br /> SAFETY--{LEEN SYSTEMS, INC. SAFETY-KLEEN SYSTEMS, INC. <br /> P4 BOX 55.5 5050 SPLIDA BLVD <br /> Sat-IDR CA 95368 <br /> ce aat�rsmare 209-545-1011 SAL IDA CA 95.'.68 <br /> SYSTEMS INC u, .EaA.ro Nm+leer TXAf�13�hib8 i 2@F <br /> 7.TrwWo*r 12 YCon paq Name US EPA 10 Number <br /> CLFnN HARBORS ENVIRONMENTAL SVC INC. MRD039322�19 <br /> a.0es�gnNed FacYay Name and Silo Address THERMO FLUIDS INC U.S.Eau 10 kffy er <br /> 1?533 SE CARPENTER DP <br /> CLACKNMAS , ClR 97015-99AR <br /> FerJls PYme: 503-788-4616 DP.E? I00025197 <br /> �a, 95.L'S.067 DeacnPgDt1 plhudn9 PrapOr SNpprg Hame.Ha7erd Gem,7D Nulrger. <br /> to.Callainers 11.Tule) 12.tin! <br /> NM and Padhq CxIX4 4Aamlij !3.Waste Codes <br /> ND. Type a;raJ:rr vt'_n+d <br /> t. NON-RCRA HAZARDWS WASTE SOLID f)M P P23 <br /> 0 (DRAINED/UNDRAINED USED bIL. FILTERS) <br /> W 2 <br /> W <br /> C7 <br /> 3. <br /> a <br /> 14.Spatial Harding Irlstrteilms andAdcitione:Irrfrmalon TSD:TPC] SPL CSG: <br /> 24H EMERGENCY#803-468-1760-CH/SKITFI-Contract retained bygenerator canfeas a ency authori .y <br /> on initial traoslaorter to add or substitutp- additinnat , <br /> 15 GENERA70R'SIOFFEROR'S COMFICATION:I bweby defte Metthe mtdents W this conslgmwtan fdy w4amiralelydmrmed ab n bt the propel&HPOrg name.art ora dasamed,pad!Aged. <br /> med(ed and 190eled'00Mrd8d.and am IA 2Y WPAel Y1 Pmpa mndean br trasppnaooRdllg la apgirlda irlgmeEor®i efid na!mal gorermaxai rsglJaWm.If eendd anpment and I am the Primary <br /> Eooft I ra*1hffi rte c t2nls of the consign nant eonblm m ft leans D1 the Ovied EPA AcglowledWwrt of Cmeem <br /> I-rosy t-w the waste nnniV Von Sigomem i (FR 26277(x)[t I rn e large qua:�tily �)!dl am a arias msrl u!nie, <br /> pamfk*-Piing alzil FII* DeY Year <br /> .Vnerna5Dna1 ship~!$ <br /> ❑impart m 11.5. Eepod from 0.5 Pod of anttylexit <br /> Tvrepader signadare;Id aMadre DrtJ3' Fele�eavirg'J 5.. <br /> W 17.TrenspottrAWodedgman!cl Rerzpl d KkaWrWs <br /> t ,Pm�dmyQed Nanrg� gnaa;re Monty Det Yea <br /> 2?I�— ams N 4 iA i' <br /> ,E.Discrepancy <br /> 'da.0 saepanby ln"bar Space ❑!)„2nti1y ❑Type Partial Repow ID Fal Rejmtw . <br /> I�ani(eN Redereme Nwnusr. <br /> tab Ahanals Faidtf for Ciar+er=6 U.S.EPR IO NLinba <br /> J <br /> V <br /> aQL. FaGf[yrL Pnd1R. <br /> sac reof A4emele Faofty[or na'atal Math Dat Yea <br /> x <br /> w19.Narardm: Moe Rerort M"ornee l Molhad Codes(h.a..ordi s for huaNars wade trwu-v dapoaal,and mcvding systaim) <br /> 4 2. 3 a <br /> 20.0ewgna,ed FmW Owner ar 0p lo,Cetry4taY n dt wmpl of ham Nora materials mmW by 1*n'drldatl exW as MW In Item 18a <br /> n6NFyped Name 5lW+a r I MOM Day vul <br /> b121 16 1 11 <br /> EPA Flynt 6700 22 EERev.12-17)Previousedmdns are obsolete DE HATED FACILITY TO EPA's a-MAN FEST SYSTEM <br /> 177872675/155P.31 <br />