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«l. sl; SHIP## 71I�i.E cc_, Please orintortvoe Form Approved. OMB No. 2050-0039 LFA Form afuu-22 (Rev. 12-11) Previous editions are obsolete. UESIGNATEU FACILITY TO EPA's e -MANIFEST SYSTEM i 9 1 i i. it Sr 1.) 14626 / 1560 1 �, f� i 14941 / 1F,� C.,i t:T �� ., ,�"_.e UNIFORM HAZARDOUS 1. Generator ID Number �_ X RIZ1000 ' 1205 a 2. Page11 of 3. iT-699ry Rte}spplgse P,hnp� o ((�3 1IL�l kt 11 !! 4. Manifest Tracking Number 1007312173WASTE SKS MANIFEST 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) SAFETY—KLEEN SYSTEMS, INC, SAFETY—KLEEN SYSTEMS, INC. O BOX 555 5 150 SALIDA BLVD SAL I DA CA 95368 Generators Phone: 6. Tr et Co n SYSTEMS INC U.S. EPA to Number TX R0012 81 Ot S 7. Transporter 2 Company Name U.S. EPA ID Number r!_.EAh, HARBORS ENV SVC INC. MAD0393221250 8. Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, T f ' NC. U.S. EPA ID Number 6121911171 1313TH STREET SACRAMENTO , CR 9582:181 h,--30jiS-4913, CA121000084517 Facility's Phone: ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, to Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt.Nol. 1. NON--RCRA HAZARDOUS WASTE, LIQUID DF G 13, 4 (AQUEOUS BRAKE CLEANER) O � O 0 z 2. NON—RCRA HAZARDOUS WASTE LIQUID DM G 13,4 (AQUEOUS FARTS WASHER SOLUTTON) , r rR, P' 9 C i 4, 4. 14. Special Handling Instructions and Additional Information TSD: SGA SAL CSG 24H EMERGENCY##800-468-1760—CH/SK/TFI--Ci)ntract retained by generator confers agency authori on fnitial transporter to add or substitute additional trans orters on enerator's behalf. 15. GENERATOR'SIOFFEROR'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, marked and labeledlplacarded, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify, 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. Gey�torslOfferors Printedped Name Signature / Month Day Year 16. International Shipments ❑Import to U.S. Ex rom U.S. Port of entry/exit: ? Transporter signature (for exports only): Date leaving U.S.: ix W 17. Transporter Acknowledgment of Receipt of Materials Tr sponer 1 Printed[Type ame Signature Month Day Year z Transporter 2 Printed/Typed Name Signature Month Day Year r- 1 B. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejectionj ❑ Full Rejection Manifest Reference Number: 18b. Alternate facility for Generator) U.S. EPA ID Number J U tai Facility's Phone: w 18c. Signature of Allemate Facility (or Generator) Month Day Year a z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1 H141 2' H141 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year z LFA Form afuu-22 (Rev. 12-11) Previous editions are obsolete. UESIGNATEU FACILITY TO EPA's e -MANIFEST SYSTEM i 9 1 i i. it Sr 1.) 14626 / 1560 1 �, f� i 14941 / 1F,� C.,i t:T �� ., ,�"_.e