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SSL SK SMP# 231218547 HIM III ill II1ll1IlIII loll 1111 <br /> 0 0 7 4 4 0 6 2 7 S K S <br /> Please print or type. Farm Approved,DMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3 Eme envy Res rise Phone 4.Manffest Tracking Number <br /> WASTE MANIFESTUS, <br /> X 8000081 nS 1 1— 0 ,4 8-1761b S KS <br /> 5.Generator's Name and Ma#ling Address Generator's Site Address(if different than mailing address) <br /> SAFETY—KLEEN SYSTEMS, INC. SAFETY—KL_EEN SYSTEMS, INC. <br /> Pp BOX 555 5050 SAL.IDA BLVD <br /> SALIDA CA 95368 <br /> Generator's Phone: 209-545-101.1 SAL I DAl Ef 1 95368 <br /> 6.Trans carter 1 y Name U.S.EPA ID Number <br /> S3 FETY= —SYST IS I j C TX R000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SA{✓ETY_KLEEN OF CAL i FORK I A U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK , CA94560;10-795-4400 CAD980887418 <br /> Facility's Phone- <br /> 90, 9b.U.S DOT Description(inducting 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.Ml. <br /> a NIDNW-RCRA HAZARDOUS WASTE, LIQUID W� TT G x 21 <br /> 0 (USED OIL) W <br /> z 2. <br /> w <br /> c� <br /> 3. <br /> 4. <br /> 14.Spedai Handling Instructions and Additional Information TSD,E VIS SAL CSG <br /> 24H EMERGENCY#1800--468--1760—CH/SK/TFI--Contract retained by generator confer's a enf y authori <br /> 15. GENERATOR'SIOFI BROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classed,packaged, <br /> markad and labeledlplacarded,and are in all respects in proper Gonditlon for transport according to applicable intematienal and national gavemmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this Consignment conform to the terms of the attached EPA Acknowledgment of Consers <br /> 1 certi€y that the waste minimization statement identified in 40 CFR 252.27(a)(if€am a large quantity generator)jr(b)(if i ami small enerator)is true. <br /> Generator'sloffror's 'ritedffy ame Signature Month Day Year <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. 0ort of errtrylexit: <br /> ? Transporter signature(for exports only): Elate laWing U.5 <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> �. Transporter t PrintelCYPY Name Signator Month Day Year <br /> KM <br /> y Tru iter 2 PrinteG yped erne Signature nth day Year <br /> l�- <br /> 18,Discrepancy <br /> 18s.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number, <br /> 18b.AE emate Facility(or Generator) U.S.EPA ID Number <br /> Facilty's Phone: <br /> W 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatrnent,disposal,and recycling systems) <br /> � 1. � 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:t:eitiftcation of receipt of hazardous materials covered by the manges'.except as acted in Item 18a <br /> Printedffyped Name � V Y�"�' Signature Month Day Year <br /> S <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. S MATED FACILITY TO EPA's e•M IFEST SYSTEM <br /> 111 1�-4gI1�LCh17 <br />