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SSL SK SHIP# 222170409 11111111111111110111111111 0 0 5 9 4 6 ? 4 7 5 K 3 Please print or type.(Form designed for use on elite(12-pitch)typewr ter.) Form Approves.OMB No.2050-0039 UNIFORM HAZARDOUS t Geriera�r 10 Number CAT 1 � 12.Pagj1 of 3. mty Res000se POo�e d.Manifest Tracking Numbor WASTE MANIFEST tii010"a46t� i/b 7 SKS 5.Generata's Name and Malang Address Generators Site Address(if different than mailingaddress) SKS V SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN SYSTMS, INC. PO BOX 555 505E SAL.IDA BLVD SALIDA CA 95358 Generator's Phone: 209-545-1011 SAIDA CA 95368 s.T%W Corte vtf�r�ie SYSTEMS INC U.S EPA 10 Number TXROOOO81295 7.Transporter 12 Company Nam U.S.EPA 0 Number CLEAN HARBORS ENVIRONMENTAL SERVICES INC MAD039322250 8.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, INC. U S.EPA 10 Number 6800 88TH STREET SACRAMENTO , GA 9582$ 916-386-4913 CAM0084517 Facifiy's Phone: oa 9b.U.S.DOT Descrowo-;iuding Proper Shipping Name,Hazard Class,IC Number. 10.Containers I I (ta! 12.Unit 13 Waste Codes tiM and Packing Group(if any); No Type Quantity Wt.Nol. X 1 UN1263 WASTE PAINT RELATED MATERIAL,3, DM P F@03 DWI 1111121118 o P6 II, D635 D839 212 w X pfflfiff BM -Dw 11 _. 242 PA i ) 1» S eec;a;hand:,).;Inst--:t,"-S arc Aa-mona !nfcrmaoor. TSD:SCA )—SA1- � 1)ERB#128.2)ERG#128• t W �'� 24 HR EMENCY #I—h@0-468-1760 (SKI TFI) i AUTH AS "AGENT—FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECES RY GENERATOR S OFFEROR'S CERTIFICATION: i nereby declare that the contents of this cons anment are h0v an;swuraterr descnxd aceve by the D oaer shpp+n;nan'-and are.-'sssfia pec<aoed amea erti iaoa�eerc acadea.an-are in aii respect.in proper Wndit-on for transport according to 80piiCati;e intemalwai and nationai Wvemmertai recuixfons if expos shipment and i am:ne Pima-y Exporter.l Ce tfy rnat the Contents of tris xiisgnta ed ment conform to me tarns at the atEPA Acknowledgment o r Coer" cerbN that the waste minirnaamn statemet t iden*fied m 40 CFR 262.27im;if i am a large quantity gereraron a" ;pd i am a small quanty genieraw',!s true k-j , erieratdrsiOfferors PrintedTyped Name Signaaae Month Day Year O(P 1 l 6.lntematronal ipmens i c F-- l__1 irr>aorl to U.S. Export,from p nen J.S. tryiexit _..._.___._--_----------_......__ ___.—.......___.___..... Transpcutar signature;fv exports only) Dale leaviry U.S 17.Transporter Acknnwtelgment of Receipt&Materials Transportat t P intedTyped Name Sig tu � MNomb ,D�ayy Y/ear t' / t -�5.� �O lJC7 i Transporter 2 Pnnted+T le rT` Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication SpaceOuantty ❑Type tJ Res due ❑Paniai Rejec4an �i FullRe escort Manhest Reference N— I . -136.Ahemale Facility ior Generator) U S.EPA 10 Number _J V laL Fachiy's Phone W 18c Signature of Adgernate Facility ior Geneolor) Month Day Year z a19.HazafdouS Waste Report Management McCwd Codes ii.e.,codas for hazardous waste treatment,disposal,and recych g sysiemsi 3. a UJI 0 1 H141 2 -Fitif � 20.Designated Faak y()vnar or operator.Cortification of receipt of hazardous matenais covered by the manifest except as noted in hem 18a Printed(Typed Name Signature t Month Day Year A/ { a r Lo -z EPS Foaay)if em P DESIGNATED FACILITY TO DE INA N STATE(IF REQU)R D)