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SSL SK SHIP# 213109569 IIIIIIIIIIII'I 'IIIIIIIIIIIIINIII <br /> 004354952 SKS <br /> Please print or We.(Form designed for use on alter(12-pitch) 'ler.) Form Approved,OMB No.1050.0039 <br /> UNIFORM HAZARDOUS 1.Gan IU Number 2.Page 1 W 3 Emergency Reaponse Phone 4.Mantast TaeM NumMr <br /> WASTE MANIFEST CAD9$2485351 1 1-B00-46H--1760 0 0 4 3�4 9 5 2 SKS <br /> 5.Generators Name and Meiling Address Generators Site Address(if diderent than mailing address) <br /> Cal-Trans Shop 10- Lodi Cal-Trans Shop 10- Lodi <br /> 1603 S B St 84S E Pine St <br /> Stockton CA 95206 <br /> Gawrators Phone: 209-333-6953 Lodi CA 95240-3108 <br /> 6.TmnSeE 1Can Name U.S.EPA ID Number TXROOOOS120S <br /> SAFETY-IFI EN SYSTEMS, INC. <br /> 7.Transpoder 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS, INC. U.S.EPA ID Number <br /> 6000 88TH STREET <br /> SACRAMENTO CA 95828 <br /> Fatl916-386-4913 C4O000084517 <br /> sPltone: <br /> ga. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers It.Total 12.Unit <br /> HM and Flailing Group if my)113.Waste Codes <br /> Nc. Type Quantity WtNd. <br /> 1 NON-RCRA HAZARDOUS WASTE, LIQUID OF G 134 <br /> (AQUEOUS BRAKE CLEANER) i <br /> Uj2 NON-RCRA HAZARDOUS WASTE, LIQUID DM �� G 134 <br /> (AQUEOUS PARTS WASHER SOLUTION) l <br /> 3. <br /> 4. <br /> 14,Special Handling lrmWctiorsaMAdtlitional Information TSD:SCA 63757869 CA37093 201423 C56:24 <br /> 24 HR EMERGENCY #1-800-468-1760 (SAFETY-KLEEN) ILIC06 `O <br /> 1-7LIc;L <br /> O RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 15, GENE RATOR'SIOFFEROR'a CERTIFICATION: I hereby declare that the contents of this consignment ere Tully and accurately desm'bed above by the proper shipping name.and are classified,packaged, <br /> marked and labeledlpiaczrded,and are in all respects in proper corrdltion for transport according to applicable intemationaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br /> 1 oam8y that the waste minimization statement identiFred in 40 CFR 262.27(a)If am a large quantity generator)or(b)(if I am a small quantity geranium)is true. <br /> Bret aPdn yped Nemo Si stun Mon Day Year <br /> cc �irk� Y o <br /> F 16. temational Shipments Elim import U.S. <br /> po ❑ExpM ham U.S. Pon of eMrylexit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> K 11.TivnsportsrArkrowledgment of Receipt of Materials <br /> Tmnapater 1 yped Name Signature Month Day Year <br /> u <br /> yr7pl <br /> Transpother7lirinteffyipecl Name Signature Month Day Year <br /> 18.Discrepancy <br /> tike.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Pmkd Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> t1 <br /> rig <br /> Facility's From: <br /> a 1&.Signature of Alternate Facility(a Generator) Month Day Year <br /> Z <br /> 19.Hazardous Waste Ration Mmagement Method Cordes(i.e.,codes for lazardous waste treatment,disposal,arts recycling systems) <br /> n 1, H141 2' H141 3. 4' <br /> 20.Designated Facility Omer or Operator.Certification of receipt o1 hazardous materials covered by the manliest except as nrled In Item 18a <br /> 1 vnnw typedame Sign III Month a Year <br /> E1AForm <br /> 87 22(50100) 214941/150 315 DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />