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SSt SK SHIF# 22S300175 <br /> P16iaw-print or type.(Form designed for use on elite(12-pitch lariter.) Form Approved.OMB No.2050-0039 <br /> UNIFQRM HAZARDOUS' 11.Gehemlor ICI Number 'k 2.Page I of I 31E 4.MwffW Tracking Number <br /> C 0"�0 a 9 d7 0 IM OT <br /> WASTE MANIFEST fl- 1 006398773 SKS <br /> 5.Generator's Name and Mailing Address Generator's W Address(If different Man marling address) <br /> Paradise Point Marina P'aPadise poin." llariDa <br /> 80?S Rio E�Ianca Ruad. 8095 kiu Blinco Rd <br /> STOCRTON A 9&219-6703 <br /> Generator's Phone: '209-9r-2—i000 <br /> T <br /> SOC�'TON- C,� <br /> 6.Trans 'Com n U.S.EPA ID Number <br /> I <br /> SA TY Ne SYSTEJ 1 S I N C T'X IR 00 0 001 0 S <br /> TTransporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Narne .,,r- :PA ID Number.TY—KLEEN SYSTEMS, INC. <br /> 6000 OBT14 STREET <br /> SACRAMENTO t a 95K-48 <br /> Facilitys Phone: <br /> ga. 9b,U.S.DOT Description(including Proper Smpp;ng Name,Hazard Gins,ID Number, 10.Contain€ss 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity mjvol. <br /> I- NON—RCRA HAZARDOUS WASTE, LIOUID DF' 0 134 <br /> o (AQUEOUS, PARTS WASHER SOLUTION) <br /> W <br /> Z 2. <br /> Uj <br /> 3. <br /> 4. <br /> 114.Special Handling Instructions and Additional Information TSD: SCA 76705317 PA2,�02 N') <br /> CSV: <br /> 2- <br /> -4 HR EMERGENCY # 800-468-1760(SAFETY—XLEEN) <br /> -79 <br /> A11TH AS "AGENT—FOR" BY BE% TO RETAIN LICENSED SUB CARRIE'RS AS NEC SSARY <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION, I hereby declare that ft contents of this consignment are fully and accurately described above by the proper shipping nam,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 EPAAcknowliadgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(9 1 am a large quantity generator)or(h)(if I am a&mail quantity generator)is true. <br /> Genera OfferoesprintedITNa } S nature Month Day Year <br /> 0a <br /> ,s 16:international Shipments I LJ import to,U.S. Export from U.S. Pod of entry/exit: <br /> Transporter signature(for exports only} <br /> Date learving,U.S.. <br /> 17.TfansporterAckro4edgm,cint of Receipt of Materials; <br /> Ax Transporter lFri - YW. Month Day Year <br /> rzk� <br /> 5, 14 ur <br /> T Month Day Year <br /> 18.Discrepancy <br /> 16a.Discrepancy Indication Space ❑ Quantity 0TYP. ❑Re-sidue 0 Partial Rejection ❑Full Riclim, <br /> Manifest Reference Number. <br /> C 18b.Altemate Facj*{or Ggoorator). <br /> Facility's Phone: <br /> I Be.Signature of Alternate Facility(or Generator) Month Day Year <br /> 119.hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> H141 2. 3. 4, <br /> 20.Designated Facility Owpeir,or.Operator-.,Certification Of 10060t of,hazardous materiipls covered by the rnqn6ast#xcW as rated kiltern t8a. <br /> Day Year <br /> EPA 8753-27- Previouse(l FMare ULrjMUd. <br /> DESIGNAT115112leA ft- -rrvtO GEN dRAT UR <br /> i 4941/VS,02 <br />