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SK SHIP# 221426128 005776635519 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 1.Generator ID Number 2.Pagg 1 of 3.E y_ se Phpge 2, 4.Mani Tracking Number UNIFORMHAZARDOUS C,AL000398 30 ' �� ' 00 776635 $K$ WASTE MANIFEST 5,Generator's Name an Mailing Addr s Generators Site Address(if different than mailing address) 1='araf isl 1 t, barilla 809E Rio Blanco Rd STOCKTON CA 95219-6703 Generator's Phone: 6,T`a e �CoW–t&9e SYSTEMS, INC U.S.EPA ID Number rkF, 7.Transporter 2 Company Name U.S.EPA ID Number a S Designated Facility Name and Site Address AF 'TY-KLEEN S STEMS, Ilsf:. U.S EPA ID Number 6000 88TH STREET SACRAMENTO , CA 9SB28 916-386-4918 i;Ft0000084S1:_ Facility's Phone: I III 9a, 9b.U.S.DOT Description(lnduding Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit HM and Packing Group(if any)) No, Type Quantity WtNol. 13.Waste Codes 1. h1ON -RCRA HAZARDOUS WASTE, LIQUID I o (AQUEOUS PARTS WASHER SOLUTION) 1 z 2. w 3. a 14 Special Handling Instructions and Additional Information TSD: SCA 72677524 P A23059 20177 //C86: 2n '4 I-IF= EMERI 0 800--468-17*64(SAF'ETY-KLEEN) ,}UTH AS "AGENT.-F(7F'" 8Y GEN TO RETAIN LICENSED SUS CARRIERS AS HECESSAR' 15. GENERATOR'S10FFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labelediplacarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 GFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator'slOfferar's ArimtedlTyped Name Signature 0i Month Day Y r AJ re �.� oS �� 32'v l J 16.Intemational Shipments F ❑Import to U.S. ❑Export from U.S. Port of antrylexit: z Transporter signature(for exports orly): Date leaving U.S.: 17.Transporter Acknewled merit of Receipt of Materials Tr p er 1 Punted ped Name Signatu M Day Y O iV 1V wt` I Z Transpo r2 P' t ed Name Signature Month Day Year 18.Discrepancy 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone. ILLI 18c.Signature of Alternate Facility(or Generator) Month Day Ye3f t— a Z CD 19,Hazardeus Waste Report Management Method Codes(i,e.,codes for hazardous waste treatment,disposal.and recycling systems) M 1' H141 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Prin ped Name l S' Month Day EPNI _ 71^2 { G3 Previous editions are obsolete. DESIGN ED FACILITY TO DESTINATION STAT (IF REQUIRED)