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SSL SK SHIP# 228516447 (IIIIII�I'I�III,III'IIIIIII�II'I'II <br /> 0069613175K5 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page i of 3.Enver enc Res nse Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS T X RbiOI�t�?Ig1 i_05 i 1—.9QVil-4 °©"-17b� SKS <br /> WASTE MANIFEST 1006961317 SKS <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> SAFETY—Y.LEEN SYSTEMS, INC. SAFETY—KLEEN SYSTEMS, INC. <br /> GO BOX 555 50.50 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209-545-1011 SALIDA CA 95368 <br /> 6.Tr n er Com an N me U.S.EPA ID Number <br /> ��FnE�Y—P'LYE�N SYSTEMS INC TXR00dlC18E20S <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA U.S.EPA ID Number <br /> 6880 SMITH AVE, <br /> NEWARK , CA 94560 CRD980887418 <br /> 510-795--4400 <br /> Each"Phone <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> His and Packing Group(if any)) No. Type Quantity WLNoI. <br /> NON—RCRA HAZARDOUS WASTE, LIQUID TT G c' 1 <br /> 0 (USED OIL) 00i ©� <br /> Z 2. <br /> W <br /> 0 <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:FVG CAL. CSG: <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retainedby generator c„nfer= a en�y at_Ithori y <br /> on initial transporter to add or substitute additiona I hi <br /> 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 classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulatlons.If export shipment and I am the Primary <br /> Exporter,I cerify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(1f I am a small quantity generator)is true. <br /> GeneratorslOffercrs Printed/Typed Name Signature �r MoDay Year <br /> 1. L U—✓_ � Z <br /> 16.International Shipments1:1 Import to U.S. <br /> r Export from U.S. Port of entrylexif <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> K 17.TmnsporterAcknowledgment of Receipt of Materials <br /> Transporter i ProtedlTyped Name Signature Month Day Year <br /> CL 0 h o1 a 121111 <br /> 0 <br /> QE Transporter PrintedrTyped Name Signature Month Day Year <br /> C <br /> F <br /> 18.Discrepancy <br /> laa.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number'. <br /> 18b-Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> L) <br /> LL Facility's Phone. <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(Le,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1' /V 31 1 <br /> 2' 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> PrntedlTyped Name r Signature ` ` 6t 15 Year <br /> r /t�� 6 <br /> EPA Form 8700-22(Rev_.12-171 Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> I) 11249i156017 <br />