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SSL SK SHIP# 229217499 RECEIVED BY S.JC <br /> Please print or type. <br /> 12/26/2019 ° Form Approved.ONISNo,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAR00113296954ft <br /> 2.Pags2 of 3.ErrtetC�Y Rgspop5e PJ�tp� 4. ni(ism Traddng Numpar <br /> TE <br /> WASMANIFEST 1 k1�D1� 4t�C 1 is 0 0 7 19 0 8 SKS <br /> S.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> A le Ft^ei ht <br /> 293 Fifth t <br /> RIPON CA 95366-0000 <br /> Generators Phorre: 866-583-5080 <br /> s.T` WVl 'XM SYSTEMS INC U.S.EPA ID Number TX 8000081205 <br /> T Transporter 2 Company Name U.S.EPA 10 Humber <br /> 0.Dawgnated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA U.S.EPA Number <br /> 6881211 SMITH AVE. <br /> NEWARK , CA 94560CAD980687418 <br /> S10-795-4400 <br /> FadWs Phone: <br /> 98. 9b.U.S.DOT Description(inckewng Proper Shipping Name,Hazard Class,10 Number, 10.Canners 1t.Total 12.Unit 13,Wasie Codes <br /> HM and Packutg G-P(d-Y)) No. Type Quantity WtNoi. <br /> 1. NON RCRA HAZARDOUS WASTE,LIQUID G 133 <br /> o ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) <br /> co <br /> Z Z. <br /> 3, <br /> 4. <br /> 14,Special Handling instructions and Additional Infom+®tion TSD:EV G 80852281 AA 16302 CSG: <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retained by generator confersa envy authori y <br /> n initial tr&ns2orter to aQd 2r sqbstitulegr <br /> 15. GENERATOR'SIOFFEFtOWS CEKnFICAT1GN: i hereby declare Utat the contents of this comignnront are fully and acct ately described above by the propefshipping name,and are classified,packaged• <br /> marked and WAled1placarded,and are in ali respects in proper condition for transport s000rding to applicable international and nawnal governmental regulations,ft export shipment and i am the Primary <br /> Exporter,I oeniffy that the contents of this correignrnent conform to the tams of the attached EPA Adunowledgment of Consent, <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I an a large quantity gener00 or 0 I am a small quantity gereraW)is true. <br /> Genefillp <br /> �s ,Mma � ignatue Month 08 <br /> 16.lrttemationai Shipments Import to U.S. ❑Export from U.S. Port of entrylevt <br /> xTransporter signature(for exports ordy): Date to ving U.S.: <br /> W 17.TransporterAGmrnvledgrnentof Receipt of Materials If <br /> LLI <br /> Transporter 1 pdmprrypd Name 1 Signature Month Day Year <br /> ZQ TransperW_TFnnted1Typed Name Signature Month Day Year <br /> tY <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity [:]Type ❑Residue ❑Partial Re)ection 0 Full Rejector <br /> Manifest Reference"bar <br /> 18b.Alternate Facility(or Generator) US.EPA)D Number <br /> J <br /> V <br /> tor+ Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Ciarierstor) Month Day Year <br /> 4 <br /> Z <br /> C9 19.Hazardous Waste Report Managernent Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C1 HZI Ile 2. 3. 4, <br /> 20.Designated Faaiity 2=02 <br /> perator.Certification of hazardous us materials covered by the manliest except as noted in Item 180 <br /> n y�Name Mont, Day Year <br /> 45 01 IZI <br /> EPA Form 8700-22(Rev.12-17) Previous edidans are obsolete. DESIGNATED FACIL Y TO EPA's e-MANIFEST SYSTEM <br /> 1)651/156030 <br />