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SSL SK SHIP# 231840345 <br /> 0074404 '133 K3 <br /> Please print or type. Form Approved.OMB No.2050-GO39 <br /> UNIFORM HAZARDOUS 1-Generator ID Number 2.-Page.1 of 3.Emer�gns Res o�tse Phone 4.Manifest Trackf Number <br /> WASTE MANIFEST TX R0000A 1 c^05 1 1-t�fDiif-4 t3-I 76 X09% <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address)1007440413 n V <br /> SAFETY-KLEEN SYSTEMS, INC. SAFETY-KLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> GeneratnrsPhone: 809-545-1011 SALIDA CA 95388 <br /> 6.T ns ��Ymp-a �NarN SYSTE14S INC U.S.EPA ID Number <br /> F� �t T X R0>iD0081 X05 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY-KLEEN OF CALIFORNIA U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK , CA 94560 <br /> CAD980887418 <br /> 510-795-44f <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity WiJVoI. <br /> 0 1 EETHYNON LENE GLYCOLCRA �SOLUTI[WASTE, D <br /> (LESS THAN 50%) TTG 133 <br /> i 2. <br /> W <br /> c7 <br /> 3. <br /> 4. <br /> 14.Special Handling lnstructionsand Additional Information TSD:EVG SAL CSG: <br /> 24H EMERGENCY#800-468-1750--CH/SK/TFI-Contract retained by generator confers agency authori y <br /> an initial transporter to add or substitute 15. GENERATOR'SIOFFEROR'8 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 labeiedlplacarded,and are in all respects in proper condition for transport a000rding to applicable international and nationarr1ft,�enwiator) <br /> tal regulations.lf 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 identified in 4D CFR 282.27(a)(if I am a large quantify generator)or(b)(if I am a smal is true. <br /> Generators/ roc's Printed/Typed Name Signature Month Day Year <br /> � 16. n emotional Shipments kw& <br /> F ❑Import to U.S. ❑Export from U.S. Port*f 't: <br /> Transporter signature(for exports only): DateS.: <br /> cc W 17.Transporter Acknowledgment of Receipt of Materials <br /> ji Transporter 1 tnteCyped Nae Signature Month Day Year <br /> 0. f `' <br /> co Q7lZo <br /> co TranlpeftT2 Printed7yped Name Signature Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ED Number <br /> J_ <br /> V <br /> Facility's Phone: <br /> W 18c.Signature of Ahermate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Ul G 1. I 2. 3. 4. <br /> R I q <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedliyped Name � � Signature Month Day Year <br /> EPA Form 8700.22 JRev.12-17) Previous editions are obsolete. EIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 1)651/156030 <br />