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SSL SK SHIM'# 218723928 III�IIIIIIII��I€IIII 111111111111111111 <br /> 01153281 6 3 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch}typewriter.) Form Approved.0i No.2050-0039 <br /> UNIFORM liAZAR0005 1 Generator ID Number 12.Pag 1 of 3.Em y e se 4.Manifest Tracking Number <br /> WASTE MANIFEST T X RQf000$12D5 f� la1005328163 S K S <br /> 5.Generators Name and Mailing Address Generator's Site Address('rf different than mailing address) <br /> SAFETY-KLEEN SYSTEMS, INC. SAFETY-KLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209`545-1011 SALIDA CA 95368 <br /> s.Tffde�l omTrt�v SYSTEMS, INC. U.S.EPA 10 Number T X 8000081205, <br /> 7,Transportter�2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS, INC. U.S.EPA ID Number <br /> 6000 88TH STREET <br /> SACRAMENTO , CA 95828 <br /> 916-386-4913 CA0000084317 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Conlainers }1 Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity wt./Vol. <br /> o X 1. UN1263 WASTE PAINT RELATED MATERIAL,3, DM o� P F003 D001 D016 <br /> D022 D035 212 <br /> W <br /> L X 12.. WABTE Pi ED MAT RiAt P F0 , <br /> 3 PE; 11 Rg(BIl ��d <br /> D 2 212 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD'SCA SAL CSG <br /> 1)ERG#128.2)ER15#128• <br /> 24 HR EMERGENCY #I-A1011011-468-1760 (SK / TF I) <br /> AUTH A "AGENT-FOR" BY GEN TO RETAIN LICENSED 9UB CARRIERS AS NECESSARY <br /> 15. GENERATOR'SlOFFEROR'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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable intematonal 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 Consent. <br /> I certify that the waste minimization statement identlfted in 40 CFR 262.27(a)(01 am a large quantity generator)or b)_Vall quantity gen or)is true, <br /> GOK!to�sfoffercr` 1-7 <br /> s i rin ped Name Signature ay Y <br /> om. <br /> 16.Intern ional hipments <br /> T-- ❑Import to U.S. ❑Export from U.S. Po <br /> t lexit: <br /> Z Transporter signature(for exports only): Dat ea <br /> U.S.: <br /> Or 17.Tran rter Acknowledgment of Receipt of Materials <br /> T spo 1 Printedifyped me Signature Mgnth Day ea[ <br /> M A a vV— - -= <br /> a Tr spo 2 Prin IfypedTlame Signature Mol Day Year <br /> a <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space1:1 <br /> quantity Type ❑Residue ❑Partial Rejection ❑Fill Rejection <br /> Manifest Reference Number: <br /> 18b.Altemale Facility{or Generator) U-S.EPA ID Number <br /> .:a <br /> U <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal.and recycling systems) <br /> � t H141 2. 7dq <br /> a <br /> 20.Designated Fa Owner or Operator:Certifiq h of receipt of hazardous materials covered by the manifest except as noted in Item 16a <br /> Printedlfyped Signature Month Day Year <br /> EPAp�rl)$79Q; f�. t vi r soen DESIGNATED FACILITY TO DESTINATION STATE 1F REQUIRED) <br /> 11 ! 9� U f <br />