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SSL SK SHIP# 219%8885 I I�IA�IIIIII II IIII II�� I� II� <br /> 0 0 5 5 2 1 1 4 7 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Pa 1 of 3 E r cy a nse 4.[tAanifestTrackln Number <br /> CAT0015613968 1 - �- �° 055211 <br /> 4 7 SKS <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generators 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 /> Gererators Phone: 209-545-1011 SALIDA CA 95368 <br /> 6.T9*1�fV—WtgreSYSTEMS, INC. U.S.EPA IDNumber TXR000081205 <br /> 7.Transporter 22 Company Name U.S.EPA ib Number <br /> 8.Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS, INC. U.S.EPA ID Number <br /> 6000 88TH STREET <br /> SACRAMENTO , CR 95828 <br /> 916-386-4913 CA0000084517 <br /> Facility's Phone: <br /> ga 9b.U,S-DOT Desrx ption(including Proper Shipping Name,Hazard Class,ID Number 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> o (AQUEOUS BRAKE CLEANER) <br /> 2. NDN—RCRA HAZARDOUS WASTE LIQUID DM 20Lu <br /> E 134 <br /> (AQUEOUS PARTS WASHER SOLTION) <br /> S TS W <br /> 4. <br /> 14,Special Handling Instructions and Additional Information TSD:SCA <br /> SAL C U Z C5q'4k-f8g <br /> 24 HR EMERGENCY #1-800-468-1768 (SK / TFI) <br /> RUTH AS "AGENT—FOR" BY GEN TO RETAIN LICENSED SUR CARRIERS AS NECESSARY <br /> 15. GENERATOR'S10FFEROR'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,package <br /> marked and labeled/placarded,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 cartiy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> certiy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator}or(b)(if I am a small quantity generator)is true. <br /> t rslOfforo Printedfryped Name S :" Month )Day Year <br /> 18,International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(far exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> ~ porter 1 Printed fiyped Name Si Month Diary Year <br /> r¢n Month Day Year <br /> Q®r1gWppArter2ntedfTyped Name Sign re <br /> 18.Discrepancy <br /> 1 Ba.Discrepancy Indication Space ❑ Quarit4 ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) US.EPA ID Number <br /> J_ <br /> V <br /> u4 Facility s Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> H 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> LU <br /> I. <br /> z. H141 3 �1✓1 <br /> 20.Designated Fa iy Owner ar Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prlrtedlryped a Signature � Month Day Yerar— <br /> Y� <br /> EP <br /> l�ir4b7 71(&Y.I1-p5� e�iqu gdjtign��r gb )14941��� DESIGNATED FACILI DESTINATION STATE(IF IaEOUIRED) <br /> 1 1. b 6 5r6 13 7. y�+l b - :� <br />