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SSL SK SHIP# 241060063 0008797188Ks Please print or P type. Form Approved.17M8 No.2050-6039 UNIFORM HAZARDOUS 1-Generator ID Number (? ` 2.Page 1 of 3-Emergency Response Phone 4.Manifest Track' Number WASTE MANIFEST V� 1 I-8f10-46H-176a 1008879718 S KS 5-Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) SAFETY—KL£EN SYSTEMS, INC. SAFETY—KLEEN SYSTEMS, INC. PO BOk 555 5050 SALIDA BLVD SALIDA CA 95368 Generator's Phone: 209-545-1011 SALIDA CA 9536 6.T§MV_—'0ftrdT SYSTEMS ING U.S.EPA ID Number TXROOOOB1205 7,Transporter 2 Company Name U.S.EPA ID Number CLEAN HARBORS ENV SERVICES INC MAD039322250 S.Designated Facility Name and Site Address THE RMO FLUIDS ING U.S.EPA 10 Number 12533 SE CARPENTER DR CLACKAI�AS OR 97015-8988 503-788-4616 ORQ000U25197 Facility's Phone: ga gb.U-S.DOT description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)} No. Type Quantity WtNol- le 1- I ON--RGRA HAZARDOUS WASTE SOLID DM n P 223 0 DRAINED/UNDRAINED USED 6IL FILTERS) -��jV _.....__..- w x 2- W 3- ------------------------------------------------------ 4. I I 14.Special Handling Instructions and Additional Information TSD:TPO SAL CSG: 24HEMERGENCY;#800-468--1750-CH/SK/TFI-Contract rQtained by generator coffers a envy authorit in itial nitial transporter to add or substitute additional transporters on generator's behalf. 15. GENERATOR'SlOFFEROWS 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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent- 1 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or if I am a small quantity generator]is true. ,s Iwmrs Pr /Typed Name Signature Month Day Year &W 0 2 j 16.Inte lion I Shipments F ❑Import to U-S- ❑Export from U.S. of entrylexit: x Transporter signature(for exports only)7 leaving U.S-: W 17-Transporter Acknowledgment of Receipt of Materials T rier 1 PdRted/T Name Signature Month Day Year a z Transporter nted/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejecton Manifest Reference Number- 18b.Alternate Facility(or Generator) U.S.EPA ID Number C] LL Facility's Phone: thy, 18c-Signature of Alternate Facility(or Generator) Month Day Year Q z %hazardous Waste Report Management Method Codes(i-e-,codes for hazardous waste treatment,disposal,and recycling systems) G 1- H141 2- 3- 4 20.Designated Facility Owner or Operator:Certlfcation of receipt of hazardo4 materials covered by the mandest except as noted in Ile Printed/Typed Name Signature M th D Ye E 0?=? [M1@[a j1revious editions are obsolete. DESIGNATED FACILITY TO EPA's a-MA I PEST 9YSTEM