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SSL SK SHIPS 246396250 1115111111INI 009800 Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAIAR00lJ5 1.Generator 1D Number 2.Pa 1 of &Eme cy R onse Phone 4.�Aanifast Tracking Number WASTE MANIFEST TXROOODS1205 � 1--VW'4�-_1760 00900682 s Ks 5.Generators Name and Mailing Address Generator's Site Address LLrf dilFeerent than mai4ing address) SAFETY-KLEEN SYSTEMS, INC., SAFETY-KLEEN SYSTEI9S, INC- PO BOX 555 5050 SALIDA BLVD SALIDA CA 95368 Generators Phone: 209-545-1L111 SALVIA GA 95368 6'hff"4ft '`SYSTEMS INC U-S-EPA ID Number TXROOD091205 1.Trans rter 2 Com ny Name U.S.EPA IQ Number CLL�AN HA B0RS EhIV SERYIGES INC MAD039322250 8.Designated Facility Name and Site Address THE RMO FLUIDS INC U.S.EPA ID Number 12533 SE CARPENTER DR CLACKAMAS OR 97015-8988 503-788-4616 ORQ000025197 Facility's Phone: ga. 9b.U.S-DDT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HIM and Packing Group(if any)) No, Type Quantity Wt.NOI- 1•NON-RCRA HAZARDOUS HASTE SOLID DM P 223 a (DRAINED/UNDRAINED USED AIL FILTERS) as �L3 a 2. uu L7 3. 4, 14.Special Handling Instructions and Additional Information T5D-TPO SAL CSG- 24H EMERGENCYSOOD-4Ci8-17fi0-CH/SK/TFI-Contract retained by generator confers a ency authorit on initial transporter to add or substitute additional transporters on generator's behalf. 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, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national govemmental 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. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(if I am a small quantity generator)is true, eratoeslOfferors P ad Name Signature Month Day Year to I � �S 16.International Shipments F ❑import to U.S. ❑Export from U-S- Port of entrylexit: Transporter signature(for exports only): Date leaving U.S CC 17-Transporter Acknowledgment of Receipt of Materials LU TAM 1 PrintedlTyped Name Signature Month Day Year o +' a ransporW 2 P cUTyped Na Signature Month Day Year L�joej'% 6�e 1 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type lect❑Residue ❑Partial Re ion Full Rejection Manifest Reference Number: 181b.Alternate Facility(or Generator) U.S-EPA ID Number C7 rQ� Facility's Phone: W 18e-Signature of Aitemate Facility(or Generator) Month Day Year a a 19-Hazardou eport Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1- 4#A 2. 3, 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Ite Printedlfyped Name Signature - Monhh D Year r - q ,�-g A Flo" evious editions are obsolete. DESI ATED FACILITY TO EPA's e-MANIFEST SYSTEM ��-7�-7a(o-7&/f��a�