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53W ^HI'f'#' 2 3130E96S !/�C. Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3,Emer ency Reponse Phone, 4. nifest Tracking Number SKS WASTE MANIFEST 5,Generator's Name&;-rffNailing Address Generator's Site Address(if different than mailing address) 3450 auto Plaza F'k Wy •rr•,1CY CA 95876-0000 Generator's Phone: 209•-832---1400 6.Transporter 1 Compapy Name t U.S.EPA ID Number ,,Y`I ESS INC 7.Transporter 2 Company Name U.S.EPA ID Number S.Designated Facility Name and Site Address SWETY-KLEEN OF AI_.TF0RNIA U.S.EPA ID Number 6880 SMITH AVE. NEWAa.�f CA 94S605'10•-795-4400 + i6(J�34 yA a Facility's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes 1.itiiO14 RCRA HAZAfWOUS WASTE,LIQUID o ETHYLENE GLYCOL SOLUTION (LESS THAN SOY.) r` Z 2- LU c� 3. t 4. 14.Special Handling Instructions and Additional Information- &D;FVC "40 EMERGENCYOSOO--46B--1760-CHJSK/TFI-Covitract T'et.al ped 6q generator cnn+s:r•fs aqs-,nr:t; e.k,t;t, „t I T ..V 15. GENERATOR'S/OFFEROR'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 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 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. Generator's/Offeroes PrintedlType Name Signature ,. Month Day Year J 16.International Shipments ir— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Tranporter 1 Printed/Typed`Narrie l/ Signature Month Day Year a / (�! (� 1 rriV,��/. - i. _.,_ __ _ -- ._m._...-e__...-- -- Transporter 2,Printed/Typed Name SigMonth Day ay Year H 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue Pil ial Rejection ❑Full Rejection Manifest Reference Num H 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: C3 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) O 1 2. 3. 4. I�17 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 EPA Form 8700-22 CRev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR