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SK SHIP# 21907880M IIIIIIIIIII�II���llllll� llll�li lIII <br /> 0 0 5 3 2 4 0 7 1 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZAR000S 1.Generator ID Number L,AT0'dt#Zlfi 139 8 2 Page 1 of 3,E {iespp�sei pl4.Manifest Tracking Number <br /> WASTE MANIFEST SCC 005329071 SKS <br /> 5.G�e+nerator's Na Generators MpiVng���q�y'/_���� y�r�+ T r.kr. Generator`s Site Address fit different than mailing address) <br /> 7:FET Y—ff[f.. S ISTEMS, INC. J:E 1 Y -KL-LC.C_'1 <br /> PO PDX 555 5050 SALIDA PLUD <br /> SAL I Did CA 95368 <br /> Generators Pune: 209-545-1011 SAL I DA CA 95363 <br /> 6.Tjapspofterl.l_C"rwName SYSTEMS, INCU.S.EPA Ie Number thrllsl _ <br /> 7,Transporter 2 Company Name U.S.EPA lD Number <br /> 8 Designated Facility Name and Site Address SAFETY--KLEEN SYSTI'MS, INC, U.S.EPA ID Number <br /> 6000 88TH STREET <br /> SACRAMENTO � CR 95813 <br /> '316—,386-4913 CA0000084517 <br /> Facilites Phone: <br /> Be. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number. 10.Containers 11.Total 12,Unit <br /> HM and Packing Group(if any)) r– No. Type Quantity WI.NoI. 13.Waste Codes <br /> 1. NLIN-�RC RR I-iAiRRBC}t!5 WASTE, LIQUID DF -- <br /> O (AQUEOUS PRAISE CLEANER) <br /> z 2. NON—RCRA HAZARDOUS WASTE LIIlI!? DM <br /> LU <br /> — <br /> (AQUEOUS PARTS WASHER SOLUTION) <br /> 3. 11 F.,774 _ <br /> ( <br /> 4 <br /> 14.Special Handling Instructions and Additional Information R `�� 0 <br /> lLODI�-��� i 1 - '�1 4�a = Ito ? <br /> -411 <br /> !(1y4�ryI-IR/yCr'+�lE(r`'��.GENCYyy��++#��r1�-9�t'���--�17FiQt 1'�I^`h / Tr <br /> r...UTH (IS" "PR-7NT-4'� P-" nY I,''-h.� Tr, i1['T_,.}T1��1 � T/-r tl-i_i} I �,�}?i�T'_� }7m.'fli���AMS <br /> 15. GENERATOR11OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are cll packaged, <br /> marked and ladeledlpiacarded.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 EPAAcknowledgment of Consent. <br /> I ce!!4 that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(HI am a small quantiaerator)is true. <br /> Gen or' eror's PrintedlT Name � Signature � � �� <br /> li, <br /> �j'�i lel <br /> J 16.Interna <br /> nal Ship ents <br /> ❑Import to U.S. ❑Export from U-S, Port of ntrylexit: <br /> Transporter signature(for exports only): Dale aving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> a Trans er rintedlTyped Na Signalu MDay a <br /> O J r� <br /> Z <br /> Transp&ter 2 med pedNl Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Aliemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> 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 /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PdntedlTLW Name Signature Month Day Year <br /> EP�4 rr 7Q ,22�geu. Pp yiqu,,ppjtianggrp. Mete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />