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I <br /> I <br /> Please print or type.(Formdesigned for use on elite.(12-pitch)typewriter.) iform Approved.ONE No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number r �nrr ,.! _ 2.Pege,1 of4.Me <br /> 36Eme�. ft? be Tk <br /> WASTE MANIFEST o mer <br /> e? °3 8 SKS <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) (� v. �3 J;�l nJ <br /> d;t ItC, qZ - L u d C,11 1 t _ S11c=6:l 1 kt - :..-o <br /> tra a E, i7 alis, >-' ';-... fir <br /> 'f 6CKTON CA 95206 <br /> Generator's Phone: 20':1-.f ,j_.6V T73 1-,I_Iri I C dA 95:-44' 3 t <br /> 6.TTAns 1 om n e U.S.EPA ID Number <br /> �wr���:.�4S� . SYSTEMS, INc;� TXRRs00081r i�:_t <br /> 7.Transporter 2 Company Name US EP ID Number <br /> N..n <br /> �, 1 <br /> 8.Designated Facility Name and Site Address SAFErY—KI-EFN SYSTFMS, 1NC. U.S.EPA ID Number <br /> 6000 88Th STREET <br /> SACRAMENTO , CA 95828 <br /> 916--s86-451..1 CArA001�084517 <br /> Facility's Phone'. <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.N01. <br /> K 1. <br /> aO <br /> K <br /> Z z. NON—RCRA HAZARDOUS WASTE, LIQUID 4W G 134 <br /> (AQUEOUS FARTS WASHER <br /> T SOLUTION) <br /> F a-�AVED <br /> ' DEC 05 20166 <br /> 4 <br /> BY: --- <br /> 14.Special Handling Instructions and Additional Information T'SSr)SCA 71997909 CA3709 801 `6 CSG,-2' <br /> Jr <br /> 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) ( r� / + ✓ <br /> RUTH AS "AGENT—FOR" BY GENTO RETAIN LICENSEDR EC Y <br /> 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, <br /> 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 <br /> Exporter•I certify that the contents of this consignment conform t0 the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratorslOfferors Prinled/Typed Nam Signature Month Day Year <br /> 16.International Shipments - - f <br /> r Import to U.S. ❑Export from U.S -Port of <br /> ❑ <br /> z Transporter signature(for exports only)? - Date leaving U.S.: <br /> w 17:Transporter Acknowledgment of Receipt of Materials <br /> Transporief I Prmted(Typed Name Signature f' ✓ Month Day Year,- <br /> Transperter2PrintedRyp 7 Name —� -' Signature _ -NTonlh Day Year <br /> 18.Discrepancy _ IE <br /> ` j 18a.Discrepancy Indication Space ❑ Quantity ❑Typejection ❑Full Rejection <br /> ❑Residue L1 Partial Re <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> ra+. Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> h19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 14-1-44 X E z. H141 s. 4. <br /> 20,Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnnte lTypedN me' 'v �-, I Signature', Month Day Year <br /> Z � \ !C �' 1 c ( �, r ( �(V " ,- , I Irl l <br /> EPA Form 8700-22 RevF3Eb.9-05 Previous editions are obsolete. `..DFSI ATED FACILITYTO GENERATOR <br /> kd #tff�1`�' 173 )149 t/Y.`1u-iIa'r'3 <br />