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006953450SK3 <br /> Please print or hype. Form Approved.OMB No.2l)50-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.fm R pga Rha 4,Agantfeat Tracking Number <br /> AI `` ~4{' 7` Ob6953450 SKS <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if dHferent than mailing address) <br /> n I`S-P, — rf Ir�r'n 13 1.e PDFSA — �f Idrt) Gate <br /> If1501 tle�, `.f *ern. Rd Aft.n Sa~uel Mchenry 18501 St-arrfol-f Rd <br /> TRACY CA 95,=,77 Attn Lester Ctiho <br /> Generator's Phone: <br /> r�pan2�l9-814— "'74 TRACY rIA S5._77- 706 <br /> 6.Tr?�r1 O Fi.M SYSTE!�'(S IAC U.S.EPA ID Number TYR�tf�'fQtijl� Ii'05 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address ,SRFETY_KLEEN OF CAL I FORK I P U.S.EPA ID Number <br /> 6880 SMITH AVE, <br /> I�IFiJRFTk! CA 9A,56010- 795 -A400 ' CAI�980867413 <br /> Facility's Phone: <br /> 98. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(f any)) No. Type Quantify WLAIoI. 13.Waste Codes <br /> 1. NON-RI'RA HAZAF`MUS WASTE, LIQUID TT r <br /> l(lOFI"r �1T( 1 OQ� 5 ICS <br /> w JU <br /> w 2. <br /> c9 <br /> !� <br /> Ali, <br /> 3. <br /> 4 t , <br /> 14.Special KaWlrgInstructions and Additional Information T�I1+ tvrC AI)c } CSS <br /> r414 EMFRr3Fr4CY -��.760-CHfSK/TF'T--�Cont�-,ac_t. retainedEsu gener�alor confers agency autlisri .y <br /> On in!,Ual por��r, to add or, substitute additicalral tr Ps orters on rtinerator! & behalf, <br /> 15. GENOWOR-910FFE "FICATiON: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,andare classified,packaged, <br /> marked.gdfabeied/plac ded.and are in all respects in proper condition for transport according to applicable international national governmental regulations N export shipment and lam the Primary <br /> Exporter ththe contents of this consignment conform to the e terms of the attached EPAAcknowledgment of nn <br /> l waste minimization statementklentified in 40 CFR 26227(a)(if I am a large quantity generator)or f a sma uantity generator)is true. <br /> Ws Printed/Typed Name Signature Month Day Year <br /> CRUX 107 izo <br /> 16.hiemalm6i Shipments <br /> L-J Import to U.S. rt from U.S. Port of entry/ext: _ <br /> ? Transporter signature tfor exports only): Date leaving U.S.: <br /> U", gq"fadgmem of Receipt of Materials <br /> p y Signa• Month Day Year� .4misdlTyAed Name Signature Month Day ea <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> _ U.S.EPA ID Number <br /> J <br /> V <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or(ienerator) Month Day Year <br /> Q <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 2.WL;q <br /> 7- <br /> pzi� <br /> . <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br /> Prtntedlfypsd Name 'jam/' Signature Month ay Year <br /> EPA Form 8700 22 ev,12 1� Pre<<ious editions are obsolete� . <br /> { ' t �' ';q" J7.!," CsI11ATED FACILITY TA FPO'e o,.111oNIFFCT-QVQTCU <br />