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SSL SK SHIP # 227088742 11111111 I � I � III � � IIIIIII I � II1111111 0 0 6 6 6 7 0 1 0 5 K 8 Please print or type . Form Approved . OMB No . 2050-0039 UNIFORM HAZARDOUS 1 . Generator In Number T X R000081205 1 2 Pag 1 of 3 . Emgrft RBsygpse it e 4 . Manifest Tracking Number WASTE MANIFEST 1 iJYlK+ �FC +� 006687010 SKS 5. Generators Name and Mailina Address Generators Site Address (if different than mailinaddress) SAFETY —KLEE9 SYSTEMS , INC . SAFETY — KLEEN SYSTMS , INC . PO BOX 555 5050 SALIDA BLVD SALIDA CA 95368 Generators Phone : 209-545- 1011 SALIDA CA 95338 fi. T 1` *0TE SYSTEMS INC U . S . EPA ID Number TXR00008120 . 7, I . Transporter2 Com n Name U . S . EPA ID Number CLERN HRyHORS ENVIRONMENTAL SVC INC . MAD03932225 8 , Designated Facility Name and Site Address THERMO FLUIDS INC U . S . EPA ID Number 12533 SE CARPENTER DR CLACKAMAS , OR 97015 -8988 O 503 - 788 - 46160170001171025197Facility's Phone ', 9a 911 S DOT Description (including Proper Shipping Name , Hazard Class , ID Number, 10 . Containers 11 , Total 12. Unit HM and Packing Group (rfany) ) No . Type Quantity W(Nol . 13 . Waste Codes 1 NON — RCRA HAZARDOUS WASTE SOLID nM P 223 ( DRAINED / UNDRAINED USED bIL FILTERS ) a rx z 2 w 3 . 4 14 . Special Handling Instructions and Additional ntonation TSD : TPO SAL CSG : 24H EMERGENCY # 800- 468 - 1760 — CHISK / TFI — Contract retained by generator confers aggenvy author ( v on initial transporter to add or substitute additional trans7erter, on eneratar ' s behalf . 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 dasslled , packaged , marked and Iabeledlplacarded , and are in all respects in proper condition for transport according to applicable international and national governmental regulators. 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 Oddity 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. GOP , /Offi P ' Ryped Name Signature Month Day Year 16 . Intern 'oral hipments F ❑ Import to U . S . ❑ Export from U . S . art enbylexit: 3 Transporter signature (for exports only) : a caving U .S. : w 17 . Transporter Acknowledgment of Receipt of Materials 1- Tr er 1 PnntedRy Name Signature Month Day Year I c� / 4( 19 W 7ranspo r2 P tedlTyped Signature Month Day Year a 18 . Discrepancy 18a . Discrepancy Indication Space ❑ Quant( ❑ Residue ❑ Partial Reflection ❑ Full ty ❑ Type Rejection Manifest Reference Number. 180 Alternate Facility (or Generator) U . S . EPA TO Number V LL Facility' s Phone : w 18c. Signature of Alternate Facility (or Generator) Month Day Year Z N 19 . Hazardous Waste Report Management Method Codes ( i .e . , codes for hazardous waste treatmentcycling, disposal , and resystems ) 0 1 . ! II 1 2 . 3 . 4, 20 . Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PnntedfFyped Name Signature Month Day Year 11 ( 1ltq EPA �orm 8700-22 Rev . 12- 1 Previous aditio are obsolete . DESIGNATED FACILITY TO EPA' s a-M NIFEST SYSTEM i , 78726 ? F / 156 s .,