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SSL SK SHIP # 2226584542 11111111111111111111111111111 <br /> 006777838sK3 <br /> Please print or type . Form Approved . OMB No . 2050- 0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number TXR000081205 2 . Pa of 3 . Eme(ePpri Respop6e Phooe. ® 4. Manifest 7rackm Number <br /> WASTE MANIFEST 1 tivJKr 4btl 1 Yb 0 0 67 7838 SKS <br /> 5. Generators Name and Maili Adtlress Generators Site Address (if different than ma ' address) <br /> SAFETY—KLEEt SYSTEMS , INC . SAFETY —KLEEN SYST MS , Ih4 ' . <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209 -545- 1011 SALIDA CA 95368 <br /> s oWtf my SYSTEMS INC U .S . EPA ID Number TXRO00081 .205 <br /> 7 . Transporter2 Compo Name U . S. EPA ID Number <br /> CLEAN HR �BORS ENVIRONMENTAL SVC INC . MAD0393 " 250 <br /> 8. Designated Fadldy Name and Site Address THERMO FLUIDS INC U .S. EPA ID Number <br /> 12533 BE CARPENTER DR <br /> CLACKAMAS , OR 97015 - 8988 <br /> 503 - 788 - 4615 ORQ00002519 '• <br /> Facility's Phone : <br /> W . 96 . U . S. DOT Description (including Proper Shipping Name , Hazard Class, ID Number, 10 . Containers 11 . Tota 12. Unit <br /> and Peeling If an 13 ' Waste � <br /> n9 Grou <br /> HM P ( Y)) No . Type Quantity Wt.Nd . <br /> 1 NON - RCRA HAZARDOUS WASTE SOLID nal P 223 <br /> o ( DRAINED / UNDRAINED USED bIL FILTERS ) 1O <br /> a <br /> a <br /> z 2. <br /> W <br /> 0 <br /> 3 , <br /> 4 . <br /> 14 . Special Handling Instructions and Additional Information TSD : TPO Spi i SG : <br /> 24H EMERGENCY# 800 - 468 - 1760- CH / SK / TFI - Circ . e ined by geriera. tor canfr_ rs arinry authDri <br /> on initial transporter to add or substitute additional traps orterc Dn enerV: r ; behalf . <br /> 15. GENERATOR' SIOFFEROR' S CERTIFICATION : I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified , packaged , <br /> marked and IabekNplacarded , 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 0 the semis of the allached EPAAcknowledgment of Consent. <br /> cerely Nat the waste minimization statement identified in 40 CFR 262 .27 (a ) ( it I am a large quantity generator) or (q^m m a small quantity generator) is true. <br /> torsl0ffeno tetl/Typad Name Signature Month Da Year <br /> U-1 D , 15 <br /> 16 IN temati Shipments <br /> ❑ Import to U . S . ❑ Export from U . S . Po f ermylexiC <br /> ? Trans a nature (for experts only) : leaving U . S . : <br /> W 17 . Transporter Acknowledgment of Receipt of Materials <br /> K mar t Pmnted Name Signature Monty Do Year <br /> a fl I <br /> Z ons r2 medlTyp me Signature Month Day Year <br /> e-t- <br /> I IOI q Ile <br /> } 18 . Discrepancy <br /> 18a . Discrepancy Indication Space El Quantity ❑ Type ❑ Residue ❑ partial Rejection El F. 11 Rejection <br /> Manifest Reference Number : <br /> 18b . Alternate Facility or Generator) U . S . EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> Z <br /> N19. Hazardous Waste Repon Management Method Codes (i .e . , codes for hazardous waste treatinent, disposal , and recycling systems) <br /> 014 1 . I 2 3 . 4 . <br /> 1 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materias covered by the manifest except as noted in Ilam IBe <br /> Printed/Typed Name r Signature Month Day Year <br /> T4I►,�- S N <br /> EPA 0%511-16 <br /> %511-1 (RCvf VIV P vious s a editionobsolete . DESIGNATED FACILITY TO EPA' s e - MANIFEST SYSTEM <br />