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SSL 5K SHIP* 227170274 111111111lll1111!ll11ll 11111 <br /> 0 0 6 6 5 7 7 8 0 S K 5 <br /> Form Approved.OMB No.2050-0039 <br /> Please print or type. 2.Page 1 of 3. m R _P 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS 1.Generator ID Number TX R000081205 1 �' � p p 6 6 8 7 7 80, SKS <br /> WASTE MANIFEST 5� <br /> Generator':811"S TY SKL£EN ISYS II taMS�e)I lw�. <br /> 5.Genare"de Name and Mailin Address <br /> SAFETY—KLEEI SY5TEM5, INC. 5050 SALIDA BLVD <br /> p0 BOX 555 CA 95368 <br /> SALIDA 209-545-1011 SALIDA CA 95368 <br /> Generators Phone- U.S.EPAlD Number TXR000081205 <br /> 6T1gfftf4j'—" SYSTEMS INC <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Com an j Name MADO39322250 <br /> CLEAN H�1F80R5 ENV I RONiMENTAL SVC INC. <br /> SAFETY t(LEEN SY$TEMS� INC. U.s.EPA 10Number <br /> 8,Designated Facility Name and Site Address - <br /> 6000 88TH STREET CA 95828 <br /> SACRAMENTO , CA0800884517 <br /> 916-386-4913 <br /> Facility's Phone: <br /> 9a. <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> No T Quantity WtNW. <br /> HM and Packing Group(if any)) � <br /> O 111119LWAILIS AIR <br /> Q <br /> a <br /> z 2 NON—RCRA HAZARDOUS WASTE LIQUID DMdt C' 1,34 <br /> (AQUEOUS PARTS WASHER Sb&TION) <br /> 3. - D" WAR , <br /> Lr� <br /> 1252 MRM WASHER <br /> 4 <br /> 14.Special Handling instructions and Additional Information TSD.-SCA SAL Com• <br /> 24H EMERGENCY#800-468-1760—CH1SKfTFI—Contract retained by generator confers agyer' authari y <br /> on initial transporter to add or substitute additional transporters on enerator's behalf. <br /> 15. GENERATOR'S10FFEROR'S 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 labeiedfplacarded.and are in all respects in proper condition for transport according to applicable international and national governmental regulations.9 expert shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(A I am a small quantity generator)is true. <br /> nature Month Day Year <br /> GeneratorslDHeror's Printed,Typed Name Sig <br /> 5'-JLILUIE <br /> 16.Intemational Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexiC <br /> LZ Transporter signature(for exports only): <br /> Date leaving U.S.: <br /> K17.Transporter Acknowledgment of Receipt of Materials <br /> ImoTrans <br /> - porter 1 PdntedlTyped Name Signature Month Day Year <br /> 00: <br /> s'rl•4 of E ,�L Le s� • Gtr tet__ c Z 3 t r <br /> Qi Transporter2 PdntedlTyped Name Signature Month Day Year <br /> K <br /> t- <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space puantity [-]-.,a ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manriest Reference Number. <br /> t}- 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> 18c.Signature ofAlternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> y49.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste tfaatment,disposal,and recycling systems) <br /> 0 1. . _yam 2. H 141 3. +K*t- a. <br /> 20.Designated Facility Owner or operator:Certification of receipt of hazardous materials covered by the manifest except as noted in lie.18a Month Day Year <br /> PrintedRyped Name <br /> Signature <br /> Fpp o 2@v{Os�ditlRsl9TSQle1e ���T C _ DESIGNATED FACILITY 70 EPA's e-MANIFEST SYSTEM <br /> � '��44 ! b�D23 <br />