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SSL SK SHIP# 232633234 �) I�I I) I�)II�Itl II 1111) <br /> 007758653SK.s <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3. mey R s se P 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS SKS�[c <br /> WASTE MANIFEST TXR000081205 ��a- �-1 0 07758653 "V V <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> SAFETY-KLEEN SYSTEMS, INC. SAFETY-KLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Genera tor'sPhone: 209-545-1011 SALIDA CA 95368 <br /> s.Tr Sporter�l orr nvlJame SYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 2 Company <br /> Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address THERMO FLUIDS INC U.S.EPA ID Number <br /> 12533 SE CARPENTER DR <br /> Facility's Phone: CLACKAMAS � , OR 97015-8988 <br /> 503-788-4616 OR0000025197 <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 /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. NON-RCRA HAZARDOUS WASTE SOLID DM P 223 <br /> o (DRAINED/UNDRAINED USED bIL FILTERS) 0 ` 94 5 <br /> Z 2. <br /> w <br /> c7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:TPO SAL CSG: <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract retained by generator confers agency authori y <br /> on initial trans orter to add or substituteadditional transporters <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 quantity generator)is true. <br /> G rator's/Offeror's Printedyped Name Signatur Month Day Year <br /> o"Ascv, ,,f 1-1,, I 116 3 2.S <br /> 16.International Shipments <br /> F-- ❑Import to U.S. ❑Expo U.S. Port of entry/exit: <br /> M Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> TrNporter 1 Printedf??ed Name Signa Month Day Year <br /> CL <br /> Z Transporter 2 Printed/Typed Name gnature Month Day Year <br /> ig <br /> t LC,4 /1 103 1Zv <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> In 1. ' I 2. 3. 4. <br /> 1 <br /> 1 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> S <br /> 112 1 of Zd <br /> EPi Fp!!n$7Q0�2?/�(RQi1Z17 Devious editiont are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />