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L <br />-1...185-01 <br />pinacn nrin€ or twee. (Forret designed for use on elite (12 -pitch) typewriter.) <br />11 <br />Form Amoved. OMB No. 2flrm- mm <br />EPA Form 870 - (Rev. 3.05) Previous e3d s are obsolete. ) <br />1?0005346 2} <br />1 )2196380,369498-997G <br />DESIGNATED FACIL TY TO DE ATI®N STAT (IF REqutRED) <br />UNIFORM HAZARDOUS 1 • Generator to Number <br />CAD9$2343253 <br />2, Page I of <br />3, Emergency Response Phone <br />Manifost Tracking Number <br />N001078239 <br />WASTE MANIFEST <br />5. Generators Name and TAaifing Address Generator's Site Address (it different than mailing address) <br />EARS B;S 012$8 <br />.110 PACIFIC: AVENUE: BOX STORE <br />TOC.KTON CA 95207 <br />Generator's Phone: 21) 9 -- 4T7 - 11111 <br />6. Transporter I Company Name U.S. EPA ID Number <br />AFETY-KLEEN SYSTEMS, INC. TXR000050930 <br />7. Trans po ter 2,Company Narita U.S. E A ID Number <br />6. Designated Facility Name and Site Address SAFETY••KLEEN SYSTEMS, INC. 000618 U.S. EPA 10 Number <br />1722 COOPER CREEK ROAD <br />DENTON, TY. 76208 <br />940-483-5200 TXD07'7603371 <br />Fad! $Plwne: <br />Sa <br />8b, U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />Q. Unit <br />HM <br />and Packing Grotty (tf any)) <br />No. <br />Type <br />Quantity <br />W(No1. <br />13, Waste Codes <br />iQ WASTE FLAMMABLE LIQUIDS, 11. 0. S. <br />M� <br />P <br />001 <br />008 <br />018 <br />C.�ASOLINE) <br />13 <br />UT <br />UN1993 PC 11 (DO18,D001) <br />t <br />w <br />� <br />z: <br />ra <br />3. <br />4. <br />14. special Handling Instructions and additional Information S KT R C K#109818696 0 0019 6 ij 8 0 1 <br />ERG# 128 :.... ... .............. <br />K U 0 1 8 71 6 2739 353 a <br />15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and rately described above by the proper shipping name, and are dassifmd, packaged, <br />marked and laboledlptacarded, and are in all respects in proper condition for transport accorckng to applicable international and nalional 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 AcknoMedgment of Consent. <br />I certify gnat Nue waste minimization statement Identified in 40 CFR 262.27(a) (01 am a large quantity generator) or (b) (dr am a small quanfij gerierator) <br />Gener sMmysPdtdedlTyped me t Month Day Year <br />F <br />J"t <br />—r <br />1 . tntemalional Shipments ❑ Import to U.S. ❑ Export fro.S. 0 Port of entry 1: <br />Transporter signature (far exports only): Date leaving .S.: <br />tau <br />17. TransporterAck novdedgmant of Receiptaf Materials <br />Signature Month Day Year <br />TranspoWintedffyppmed <br />a <br />ran re Month Day Year <br />. 14 !n )"+'� <br />I8. Discrepancy <br />18a. Discreponcy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial &0clien ❑ Fuff Rejection <br />Manifest Reference Number. <br />18b, Alternate Facility (or Generator) U.S. EPA ID Number <br />Z <br />w <br />Facility's Plow. <br />I8c SgrtadneofMema;eFadliry(orGenwatw) <br />Month Day Year <br />Q <br />19. Hazardous waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and mcyft systems) <br />� <br />1. <br />1: <br />3. <br />4. <br />20. Designated F Q{mer or Operator. Cedifkation of receipt of hazardous materials covered by the manifest ex ed em 1 <br />Printedfiyped a f <br />EPA Form 870 - (Rev. 3.05) Previous e3d s are obsolete. ) <br />1?0005346 2} <br />1 )2196380,369498-997G <br />DESIGNATED FACIL TY TO DE ATI®N STAT (IF REqutRED) <br />