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SSL SK SHIP# 216660053 fs 3// � II(III')(II('IIIIIIIIII II�II�IIII�II <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 0 0 4 Form Approved OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST T X R00008120.`5 1 1-800-468-1760 1004842967 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> SAFETY-KLEEN SYSTEMS, INC. SAFETY-KLEEN SYSTEMS, INC. <br /> P0 BOX 55 i 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generator's Phone: 209-545--1011 SALIDA CA c 5 <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY-KLEEN SYSTEMS, INC. TYR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> SAFETY-KLEEN OF CALIFORNIA, INC. <br /> 6880 SMITH AVE. <br /> NEWARK , CA 94560Facility's Phone: 510-795-4400 CAD980887418 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt.Nol. <br /> 1. <br /> NON-RCRA HAZARDOUS WASTE, LIQUID TT G 2'21 <br /> o <br /> (USED QIU <br /> zx) rZ9 to <br /> z 2. <br /> L <br /> t9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> TSD:F VG SAL CSG: (tj� <br /> 24 HR EMERGENCY #1-800-468-1760 (SAFETY-KLEEN) <br /> 15. GENE 0 S TI I 10 : I ere y ec are t a t e con ents o hist signmenf are KVAnd accurate y descn a ve by he 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 Csent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(IN am a Jall quantity generator)is true. <br /> Generals/Offeror's Printed/Typed Name Signature Month Day Year <br /> ` <br /> 16.International Shipments <br /> H ❑Import to U.S. ❑Export from U.S. ort of entry/exit: <br /> Transporter signature(for exports only): Da leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Ce Transpo r 1 'ntedfryped Name Signature Month Day Year <br /> Z Transporter 2 Printed/Typed Name Signat Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 11ty ❑Type ❑ ❑ 1 ❑Full Rejection <br /> Quantity T e Residue Partial Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 03 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Narrle Signature Month Day Year <br /> • A <br /> EPA Form 87V-22(Rev.3-05) qreviousleditibns are obsolete. DESI ATED FAClhf Y TMIDESTINATION STATE (IF REQUIRED) <br /> 1) 11249/t--)6017 <br />