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OCT-27-2008 18:26 CITY OF LODI 209 333 6710 P.31 <br /> gsa-printortype.(Form designed for use on elite(12 ter.)ter.) Form APproyed.OMB No.2050-0038 <br /> UNIFORM HA7ARDOU3 1 1.Generale ID Number CA0983b i 2601' 2_page 1 m 3.Emergency Response Phone a.Aluml�f�sy1 eking NUMbOt Q SKS WASTE MANIFEST 1 1-800-468-1760 O v - V 89 J nJ <br /> S.G9neralces Name and Moiling Address Gerstell Site Addmee(If dlgerent loan mailing address) <br /> CITY Of LOCI <br /> 1331 $ HAM LAME ATT`N ROGER <br /> LODI CA 55240 <br /> Qeneratara Phone' 209-333-6830 <br /> 65TftipirLWW MY53`EMS, INC U.5.EPA IDNumber TXR000050930 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Desigrreted Facility Name and Sla Address SAFETY-KLEEN SYSTEMS, 1040, 000760 U.S.EPA ID Number <br /> 6000 88TH STREET <br /> 916-386-4913 SACRAMENTO CA 9S328 CACOQvOOE4517 <br /> Facll s Phone: <br /> ga, 90.U.S.DOT Descdpdon(Incloding Proper Shipping Name,Hacard Class,ID Number, 10.eontatners 11.Total 12.Unit 13.Waste Codes <br /> HM and Peddrg Group(Bany)) NO. Type Quantity wtivol. <br /> X 1HA7ARCOUS WASTE, LIQUID, N- ID. S. OF 0039 134 <br /> p 9 NA3082 PG III 0039)(ER13#171) <br /> AOUEQUS BRAKE 513LUTION(8. 3VIOAL) j S <br /> w 2- RECEIVE <br /> 3. 561 <br /> CITY of <br /> 4. tiPP SB aWCE <br /> CafTER <br /> 14.Special Handling Instructions and Additional informal SX TRCV#106061638 003335 081 0000$ 0 17 0704 25 <br /> SK AUTHORIZED F4 RETAIlf LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> '15. GENERATOR'S10FFFR0R'SCERTIFICAT10Nr'I hereby earl that the contents cloth conelgrmront are Miry and accurelaly oescAbed;abo+mby,Jha proper shipping name,and are dwelled.packaged, <br /> marked and labeled/placarded,and am in all m6mots In proper rpnditian tar transport according to eppllcable Nlemational and national gove'mmmnfel regulators.If expos shipment and I am He Primary <br /> EApgmer,I costly that the contents of this consignment conform to the terms of tre attached EPAAcknowledgmanl of Consent <br /> I call that the weave mininumbon statement Ider"ad In 40 GFR 28227(a)(if I an a large quantity ganani or(b)(If I am a small quem(y generator)Is we. <br /> es onhac(a Pdn yped Name .. .. Slgtlslu nth Day Yaw <br /> Gut - S n7 <br /> —+ a. memelional Shipmenla <br /> F ❑Import to U.S. ❑EY.poA tram U.S. Pont of enhyloxiL' <br /> = Ttansportersignature(for exportsonly): oats IsaftU.S.: <br /> W 17,Traasporlerftnmvledgmenlof RecelptofMatai <br /> TraAyoilfjer l Pnntednypsd Name Signature / Month Day Year <br /> %J%./�i)i� rte /ICif.•lxo..a�. C� 1S 7 <br /> a Transpalor2 AA yped Name Signatlue ` Month Day Year <br /> K <br /> F <br /> 18a.I01screpanoy,Indication Space ~❑ Quantity, ❑Type 11 Residue ❑Penial Raladien ❑Full RejecAian <br /> Manifest Reference Number, <br /> lab.Allemale Facillry for Gani mmr) U.S.EPA ID Number <br /> U <br /> W Facility$Phone: ^ <br /> WO 1ec.Ngroatum afAttemale Faulily(or Generator) Month Day Year <br /> G <br /> z <br /> ss.Harardous Waste R*n kfanagementMamad codeg p.e,.c9des forharerdous waste rreamenl.disposal.and regcling systems) <br /> 1' M.'41 2' 3' 1 <br /> . 4- <br /> 20,Deslgraled Fad' Owner a Operator:Csrtiera5on ipl of haeardous materials covered by the ma ir9el excepl as nded in Ilam Ida <br /> Pdnliulf"ed naoae Month OaY Year <br /> 'l.)Oc7VUHJ (t1e',3-05) Prevloused3jnsareobeolats. 4) • DESIGNATED FACIUT`,(;TO GENERATOR <br />