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SK SHIP# 22S300175 111111111111111 oil I I! <br /> 0 0 6 3 9 a 7 7 3 S K S <br /> Please'print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.205 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number c'A 1 0--0()3 9—8 73 —mitgorn jh�ng 4.Man Tracking Number <br /> WASTE MANIFEST cT77 006398773 SK <br /> 5.Generator"Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Paradise Point Mariiia Paradise Point Marina <br /> 8019S Rio Blanco Road. 809S Rio Blanco Rd <br /> S <br /> TOCKTON CA 95219-9763 <br /> Generator's Phone: 209— r—,2-1000 STONTUN C A 9S_21 i?`—6 <br /> 1.TgAf�y�orVtt9SYSTEMS 'INC <br /> 1pg U.S.EPA ID Number T V R 0()01081 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 0 8.Designated Facility Name and Site AddressSAFETY—KLEEN SYSTEMS, INC. U.S.EPA ID Number <br /> 6000 SETH STREET <br /> SACRAMENTO CA 96828 <br /> Facility's Phone: 916-386-4913 1['A 0 0 0 OU",8 1 S, <br /> 9b.U.SDOT Description(including Proper Shipping Name,Hazard Gins,ID Number, 10,Containers 11.Total 12,Unit <br /> cc HM and Packing Group(if any)) No. Type Quantity WuVol, 13.Waste Codes <br /> 1. NON—RCRA HAZARDOUS WASTE, LIQUID DF G 134 <br /> (AQUEOUS PARTS WASHER SOLUTION) <br /> LJ 2. <br /> co <br /> U? <br /> 3 <br /> co <br /> 4. <br /> X 14.Special Handling Instructions and Additional Information <br /> TSD: SCA 76705317 PA23059 201820 CSG:23 <br /> 0 <br /> 24 HR EMERGENCY # 800-468-1760(SAFETY—KLEEN) <br /> AUTH AS "AGENT—FOR" 14Y GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <br /> 15, GENEPATOR'SIOPFERORIS CERTIFICATION: I hereby declare that the contents of this consignment 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)(if I am a small quantity generator)is Due. <br /> Generatoesil eroes�,Printedr�519ar SignatureMonth Day <br /> lit <br /> E <br /> =a 16.Inteon-ational Shipments <br /> 11— 0 import to U.S_ El Fw from U.S. Port of entryie& <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 0 17.TransporterAcknowledgment of Receipt of Materials <br /> ILI <br /> OFe Transporter I t rm yped Name __f Signature Month Day <br /> ay <br /> Trinted(Typed Name Signature Month Day <br /> It/) 18.Discrepancy <br /> I Ba.Discrepancy indication Space D Quantity Type t J Residue ❑Partial Rejection ❑Full Rejector <br /> Manifest Reference Number: <br /> U.S.ERA IQ NumWr <br /> Facility's Phone: <br /> C3 <br /> Lu 18c-Signature of Alternate Facility(or Generator) Month Day <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,4tO recycling systems) <br /> LU 13. <br /> H141 <br /> 4. <br /> 20,Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrinWayped Name Signature Month Day <br /> FPA Form.87Q0,-22 Rev.A 5 1 edillon*are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQU4 <br /> A <br /> ,4 Precious 26023 <br />