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� �; L . SK SF-IIP # c? t7 � 97409 II � IIIIII' IIIIII ' III � I � III � I � IIIIIII ) • 0066 !l7504SKS Please print or type . Form Approved . OMB No . 2050 - 0039 1 . Generator ID Number 2 . Pa e1 of 3 . � m R s e P; 4 . Manifest Tracking Number UNIFORM HAZARDOUS TXRQ+ OVf (� 812Or g �• � �} ��- ' �' �' 0 0 6 6 8 7 5 04 SKS WASTE MANIFEST 5 . Gen rotor' s Name and Mailin Address Generator' s Site Address if different than mailin address ) S � FETY — KLEENq SYSTEMS , ING . rAFETY — LEEN SYST � MS , INC . PO BOX 555 5 + 50 SALIDA BLVD SALInA GA 953b8 � � 9 - 545 - 1011 SALIDA CA 95368 Generator's Phone : s ' T� ! ��'tCtV SYSTEMS INC U . S . EPA ID Number TX RO � � 081 � � 5 7 . Transporter 2 Company Name U . S . EPA ID Numf �er 8 . Designated Facility Name and Site Address SAFETY — KLEEN QF CALIFORNIA U . S . EPA ID Number 688Q► SMITH AVF . NEWARK , CA 9456 510 - 7 '35 - 44QttD CAD9F� QM887418 Facility' s Phone : ga 9b . U . S . DOT Description ( including Proper Shipping Name , Hazard Class , ID Number, 10 . Containers 11 . Total 12 . Unit HM and Packing Group ( if any) ) No . Type Quantity Wt . Nol . 13 . Waste Codes t . A tJflN — RCORHAZARDO !) S WASTE , LIQUID ?' T != r ' 1 o ( USED IL ) i S37 LID i w 3 . 4 . 14 . Special Handling Instructions and Additional Information jCI} � EUG SAL � 4H FME !? GENCY # Et � A - 4F� 9 - 176Qt — CNISY, / TFI — Contrast rQtainef� 5y generator confers af� ency attthor x . on initial trans Orti✓ r to ads' or sta !•rstitt� te additional trans or- + ers on ener^ tor " =_. tret� alf . 15 . GENERATOR ' SIOFFEROR ' SCERTIFICATION : ( hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name , and are classified , packaged , 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent . I certify 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 fferor' s Prinled /Typed Name ature Month Day Year ► Z r � ntemational Shi ments F— ❑ Import to U . S . ❑ Export from U . S . Port of entrylexit : ? Transporter signature ( for exports only) : Date leaving U . S . : � 17 . Transporter Acknowledgment of Receipt of Materials w � T sporte 1 Printed/Typed Na ignature � � Month Day Year Z er 2 PrintedlTyped Name Month Day Year 18 . Discrepancy 18a . Discrepancy Indication Space ❑ Quantity ❑ Type Residue j j ❑ Partial Re ection Full Re ection Manifest Reference Number : F 18b . Alternate Facility ( or Generator) U . S . EPA ID Number J v LL Facility' s Phone : w 18c . Signature of Alternate Facility ( or Generator) Month Day Year Q Z 19 . Hazardous Waste Report Management Method Codes ( i . e . , codes for hazardous waste treatment , disposal , and recycling systems ) 20 . Designated Facility caner or Operator : Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature Month Day Year i EPS } ot "� ��+t�r' ( F�e� �211Z ) Previous a itions are obsolete . D S ED FACILITY TO EPA's e - ANIFEST SYSTEM