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Ss(- SK SHIP# 23009110176 111111IIIIIII111111IU111111111111 <br /> 007276599SKS <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emer enc R Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST TX 84100081205 — � —t -'7�' 007276589 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different Ihan mailing address) <br /> SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN SYSTEMS, INC, <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generata'sPhone: 209-545-107.1 SALIDA CA 9536P_ <br /> 6.Tmnssyyoateer 1 y Name U.S.EPA ID Number <br /> SRFETYEEN SYSTEMS INC TXR0000r^-.' <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD03931' <br /> 8.Designated Facility Name and Site Address THERMO FLUIDS INC U.S.EPA ID Number <br /> 12533 SE CARPENTER DR <br /> CLACKAMAS , OR 97015-8988 <br /> 503-789-461P, 0131200121025197Fadli 's Phone: <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> NON—RCRA HAZARDOUS WASTE SOLID DM r� G' ? <br /> 0 (DRAINED/UNDR.AINED USED bIL FILT_F'- 6 aSD <br /> z z. <br /> w <br /> b� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:TPO CSG: <br /> c"d, EMERGENCY#800-458-1760—CH/SK/TFI—Centract r=tamed by genaratnr confers a ency at-Ithori y <br /> in * _ + r <br /> 15. GENERATOR'SIOFFEROR'S CE IFICATION: hereby declare that the contents of this consignment are fully and accurately described a ve by the proper shipping name,aid are classified,packaged, <br /> marked and labeledlplacarded,and are In all respects in proper coni for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify mat the contents of this consignment conform to the temu5 of the allached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(d I am a large quantity generator)or(b)(if I am a ntity generator)is true. <br /> GepRratWs/ es Pdn yped Name Signa Month Day Ye <br /> I^Cy` :F� ar <br /> d I <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Ex m U.S. Port o(enhyledt <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TranspoMrAdinowledgment of Receipt of Materials <br /> K Trayp�sp�oit_er 1 PrintedlTyglea Name Sign Monty Day ^Y1ear <br /> a 1''I'-n�y^ UC.IT141- <br /> Transporter <br /> ryV <br /> Z Trans er2 Printedfryped Name S' Month Day Year <br /> i18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity bty ❑Type E:1 Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number. <br /> 181b.Attenuate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4 <br /> 1 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest cept a ed in m 18a <br /> Pnnted7fyped Sign;gWD <br /> Month Day Year <br /> IZ f2 ZO <br /> EPA Form 8700- Rev.t2-17) Previous editions are obsolete. EVATE::—S=IL1=TYT0 EPA's e-MANIFEST SYSTEM <br /> 1)7872676/156033 <br />