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SSL SK SHIP# 22t.=.1r438 111111111111 111 <br /> Q069613O59K6 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3. mere R¢sppgse Phgr�. 4.Man"rfest Tracking Number <br /> WASTE MANIFEST TX R00008ar_'0"� ma 006961308 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(i1 different than mailing address) <br /> SAFETY-KLEEN SYSTEMS, INC. SAFETY-KLEEN SYSTEMS INC. <br /> PO BOY 55`� 50-JO SALIDA BLVD ' <br /> SALIDA CR 95368 <br /> Generators Phone _�'"-545-101.1 SAI.I1:A CA 95368 <br /> 6.Tr�ggppe[er�Cpmp�ny�ama SYSTEMS INC U.S.EPA ID Number TXROk`�0f�j8 i:.0`>>� <br /> 7.Transsppoorter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address <br /> SAF'E'`Y-Ki EEN OF CALIFtLIPNIA U.S.EPA ID Number <br /> 6.880 SMITH AVE. <br /> NEWARK CA 94550 <br /> 5101-7 95-4400 <br /> Facility's Phone: <br /> c:-1D9ai <br /> ga 9b.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)) 13.Warta Codes <br /> No. Type Quantity WLNoI. <br /> IX 1 Nr N--RCRA HAZARDOUS WASTE, LIQUID ?T <br /> o .LSED t_IIL) 001 <br /> w <br /> Z 2. <br /> W <br /> U <br /> 3, <br /> 4. <br /> 4- <br /> 14.Special Handling Instructions and Additional Information TGr):FV f �",.;' <br /> cL CSE;: <br /> 24H EMERGENT Y#80th-458-171=0-CH!SVI.TFI-Contract retained by ganaratur ronfe.^s a eriry ai.1tLr�ri .y <br /> on initial trans orter to add ub ti 'te n r -t r + <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 labelediplacarded,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 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 quantitygenerator)or(b)(if I am a smell quantity generator)Is true. <br /> GeneraloeslOHerors Printed/Typed Name Sign ture Month Day Year <br /> aid I3L) Iq <br /> 16.International Shipment <br /> i- <br /> 1:1 Import to U.S. ❑Export from US, Port of entry/exit. <br /> ? Transporter signature(for exports only): Date leaving U.S.. <br /> w 17.Transporter Acknowledgment of Receipt of Materials ' <br /> Transporter 1 Pnnted7ryped Name Sign re Month Day Year <br /> IckJi1 5 <br /> CO) 1 Sl 17 <br /> Transporter 2 Pdntedlryped Name Signature Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication SpaceEl <br /> Quantity Type 1:1 Residue ❑Penial Rejection El Full Rejection <br /> > Manifest Reference Number: <br /> F 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 /> N19.Hazardous Waste Report Management Method Codes(i.i codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 20..Designated Facility Owner or Operator:Cent ion of receipt of hazardous materials covered by the manife except as Ued in Item 18a <br /> 1 Pn yped Name t Month Da Ye <br /> Xkyj <br /> EPA Form 700-22(Rev,12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 1) 11241/15601 : <br />