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or:ro or Laljornla—cnvlranmental YraiscT,On Agency <br />f rm Approved OMB No. 2050-0039 (Expires 9-30.99) See Instructions OR back ge b. Department of ToXk Substances Control <br />F1lease print or type. Form designed for vee on elite (12•piklei iy�write�r.R n I Sacramento, California <br />1Z <br />4 im <br />O <br />w� <br />JZ <br />fW <br />3 <br />0 <br />m00 <br />v <br />N <br />`Q <br />6 <br />0 <br />oar <br />ox <br />U.1 <br />I— <br />Z <br />LUV <br />LU <br />LU <br />Ck <br />a <br />Z <br />0 <br />a <br />Z <br />W <br />T <br />t— <br />W <br />J <br />d <br />N <br />Ix <br />0 <br />} <br />W <br />C? <br />Cr <br />4ss <br />LU <br />LU <br />U- <br />0 <br />W <br />h <br />Q <br />V <br />UA <br />Ptd Q%, A)0000209668 <br />DISC 8022 (1 99 <br />EPA 8700-22 <br />DO NOT WRITE BELOW THIS LINE. <br />P1r,e CitNf.RATOR RN0S THIS GgpY 10 bT$C WITHIN 30 DAYS <br />'fes. P.O. flax 400. $Ucromento, CA 95812.0400 <br />UNIFORM HAZARDOUS <br />1. Generator's US EPA ID No. Manifest Document No. ," <br />2. Page 1 <br />Information in the shaded areas <br />WASTE MANIFEST <br />C �' Ct L� C) a $ %F� `r f �• C{ <br />j <br />is not required by Federal law. <br />/ r 1 <br />of <br />4SAN <br />2, 0,m rotor's Nome and ilKATHY ing�Address .+ N <br />RRIS <br />A State, Mani, st Document NumberATTN <br />rr�� 7 a� �g <br />P.Q. BOX 6004 <br />G•� (G19® <br />s. siaro Ge1`14 to ID <br />R AMO N C A 9 4 5 8 3 •- 0 8 0 4 <br />4. Generator's Phone 12 0 9 1 V7 8 *- 5'5 5 S <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C, State Trariaporter's ID fft <br />SAFETY—IKLEEN SYSTEMS, INC 0 <br />D. Tronsporter'sPhone <br />SbQ 669-51314.0 <br />7 Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporters ID [R sv .] <br />R. • transpcxmrts Phone <br />9. Designated Facility Noma and Site Address00 0658 10. US EPA ID Number <br />G, P "D3 <br />6� <br />14f 1PI <br />SAFETY-KLEE�N SYSTEMS, INC, <br />H. Facility'sfl one <br />3700 L,A,GRANGE 'ROAD RYD05 3 348108 <br />SMITHFIELD KY 40068 1 1 1 1 1 1 1 1 1 1 1 1 <br />502 845-2453 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Contoiners <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />t. Waste Number <br />No. <br />Typo <br />a. RSA HAZARDOUS WASTE, SOLID, N.O.S. <br />stem 751 <br />( BENZENE) <br />UM <br />� <br />PPA/Other <br />9 NA3077 PG III (DOI.6)( ERG#171.) <br />bole, <br />N <br />b. <br />State <br />E <br />EPA/Other ' <br />R <br />A <br />T <br />c. <br />seal. <br />0 <br />EPAlO1he. <br />R <br />d. <br />State <br />[5W01hr <br />1.. Additional Descrlptions for Materials lasted Above <br />K. Handling iWas for Wastes <br />Usted Above <br />1,A►) D419 D-008 <br />m. <br />b. <br />IS. Special Handling instructions and Additional Information I"'}..F' S T R rT �kl Q .t. 2 8 7 6 2 7 0001-9977-14 <br />MERGENOY RESP 800--460-1.760(24 HP). IF LINDELIVERABLE RETURN TO GEN.ErmroR, <br />SK CORP AUTHORIZED TO RETAIN LICENSED SUBSEQUENT" CARRIERS AS NEc;ESSAIRY. <br />SiCDOT A: 1331 D; C: D.- <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurate) described above by proper shipping name and are classified, packed, <br />marked, and iobeled, and are in oil respects in proper condition for transport by highway occording to applicable international and notional government regulations. <br />IF I am o large quonfiy 0"at tYor, I certify that I have o program in place to reduce the volume and tonlclty of waste generated to the degree I have determined to be economically <br />that I hhove the method of treatment, storage, or disposal currently avoilable to the future throat to human health <br />practicable and selleected practicable me which minimizes present and <br />if I i have faith best is <br />and the environment; OR, am a small quantity generator, mode a good effort to minimize my waste generation and select the waste management mofhod that <br />available to me and that I can offard. <br />ri�tedn d Name '• <br />. 3 . '`:' 1.e <br />C' <br />a.4 g <br />Y! <br />T7Tbdo <br />e',St�gttotur <br />;t. 1 <br />e17. <br />d, <br />t, d <br />T <br />i <br />Transporter 1 Acknowledgement of Receipt of Materials 4 04 4 <br />R <br />Printjmyd/jTy/ped N4Mr y ) <br />Signature y / f ' 1� �— �- <br />A ^%^ <br />, <br />Month y)ayj( %qrp� <br />/j/ <br />S <br />.i( /Lr- '—^' j !' a._r�I °'�f <br />!"�C .!ll <br />/ 4 / 1 t'„ <br />P <br />g <br />1 A. Trans flet 2 Acknowleciement of Receipt of Materials <br />TPrinted/Typed <br />Name <br />Signature <br />Month Day Year <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />1 <br />20. Foeilit Owner or orator Certification of recei f of hazardous materials <br />covered 6Y this manifest except as noted in Itan 19. <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />Y <br />Ptd Q%, A)0000209668 <br />DISC 8022 (1 99 <br />EPA 8700-22 <br />DO NOT WRITE BELOW THIS LINE. <br />P1r,e CitNf.RATOR RN0S THIS GgpY 10 bT$C WITHIN 30 DAYS <br />'fes. P.O. flax 400. $Ucromento, CA 95812.0400 <br />