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SSL SK SHIP# 2227324170 <br /> 0 0 6 7 7 5 8 6 9 S K S <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Pa e 1 of 3. m R e 4.Manifest Trackin Number <br /> UNIFORM HAZARDOUS TXRO>�0081;�tb 5 g 1 �� -��°�- Q1 9 (►��[[((�� <br /> WASTE MANIFEST 006775869 SKS <br /> 5.Generator's Name and Mailin Address Generator's Site Address if different than mailin address) <br /> SAFETY-KLEEh� SYSTEMS, INC. SAFETY-LEEN SYSTel INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> y SALIDA CA 95368 <br /> Generator's Phone: 205-545-1011 SALIDA CA 95368 <br /> 1.Trgotf SYSTEMS INC U.S.EPA ID Number TX ROOOOB 1205 <br /> 7.Transporter 2 Comppianny�Naame� 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 <br /> CAD980887418 <br /> 510-795-4400 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. NON-RCRA HAZARDOUS WASTE, LIQUID TT G 221 <br /> o (USED OIL) O t <br /> z 2. <br /> w <br /> CD <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD C EVG SAL CSG. / <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract retained by generator confers aggency authori y <br /> on initial transporter to add or substitute additional transporters on enera tor' s behalf. <br /> 15. GENERATOR'S/OFFEROR'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 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 <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 quantity generator)or(b)(if I am a small y0tity generator)is true. <br /> Generator's/Offeror's Printed/Typed Name Signature Month Day Year <br /> b,+W Z-A"-t I 6LL,- JLZ I / 1 7 1 1� <br /> J 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Printed/Typed Name Signature ( - Month Day Year <br /> D N -r = �► l ? <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type ❑Residue Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ra+ Facility's Phone: <br /> w 18c.Signature of Alternate 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 L � 2. 3. 4. <br /> 20.Designated Facif y Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name Signature Month Day Year <br /> 4 F!97-J--P A-1� I \f 11 171 <br /> EPA1)11F�QJJ jl�t h. ) Previ s editions are obsolete. TSFWED FACILITY TO EPA's a-M NIFES SY r"M <br />