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OCT-27-2008 18:26 CITY OF LODI 209 333 6710 P.32 <br /> Pleas@,print or type.(Form desligned for use on elite(12-911 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 31-801)-4 <br /> .Emergency Response Phone 6.MaoIFBM l'Acaln Numbte-r <br /> CAD9Ci3672641 0004�74G`3 SKS <br /> WASTE MANIFEST — p —4 $-1.764 L <br /> 5,Generator's Name and MaRngAddress Generator's SlteAddiess(If different than mailing address) <br /> CITY OF LODI <br /> LORI S HAP! LANE ATTN RUDER <br /> CA AcsL40 <br /> Comeamor's Phone: 249-333-6834 <br /> 6.Tran' ¢art Cpm Name U.S.EPA Number SAF SAF .Y�KLN SYS'tEP15r INC. <br /> 7.Transporter 2 Company Name U.S.EPA ID Nfenbee <br /> e.Designated Facility Name and She Address SAFETY—KLEEN SYSTEMS, INC. 444764 U.B,EPA 10Numher <br /> 6440 SSTH STREET <br /> SACRAMENTO CA 9SB2e <br /> 91 b-356—+6413 rt+a004Zr8A S 17 <br /> fadll s Phona� <br /> go. 9h.U.S.DOT 09edtlptlon(Inpluding proper Shipping Name,HazaN Class,ID Number, Conclners 11.Total 12.Unit 13,Was;a CodDs <br /> HM and Paddng Gfodp Qf any)) No. Type Quantity WVVol. <br /> X 'HAZARDOUS WASTE. LIQUID. N. C. S. AF 6 D0391134 <br /> 9 NA3432 PIS III (D039)(ER0#P171) <br /> AQUEOUS BRAVE 90LUTION(S. N/DAL) <br /> i 2. <br /> UJI <br /> 3. <br /> 4. <br /> 16.Spadsi Hemming Instructions and Addll'arallMomMtlon �K TRCKRI08318614 4433$92786 4044370797 4716 2S <br /> C <br /> 15. GENERATOR'SrOFFERORS CERTIFICATION: I hereby declare that the content'o(d11e consignment are fMly and accurately described above by the proper shipping name,and are da'IOed,packaged, <br /> marled and labslsd(plerarded,and are In all respects In proper condition for transportaccordirlg to applicable intem iamoland migovemmerdel regulations.If export shlDmenl and 1 am the Primary <br /> Exporter,I Penny that the cpntoata of HE consignment conform to Na terms of the abethed EPA Ackncwladgment of Consent <br /> 4, I Ic#Mfy oatgre wastarjrlmlzation staMwtl ted ln40CFR26227(a)(glamelwpquattygerWmtor)or(b)(ifI a uentlly ganwalor)is lnre. <br /> G eratofsl0lfem(/a�Prn I d/TTyped Name r/ �� {/ gnaWre C-/ Month Day Year <br /> A, `.. 7(1"� r c7 7 <br /> 1flAntiefialhanalShipmeras <br /> ❑Import to US, ❑EW from U,S. Ponof erdy'/axic <br /> Transporlar sigmalum(far axports only): Dere leaving U.S.: <br /> W 17.TaneporlerAckroMMedgment of Rai of Materials <br /> F" Tro sportgr1 Pdmadngped Name Sgnetu r Month Oay year <br /> d: r :, <br /> G Tranaparlar 2 PirmlecirtypecName Signature Month Day Yaer <br /> 16a.Discrepancy Indloodhin Space ❑ Ouandly ❑TYPO ❑Rwki ❑Partial Rejection ❑Full Rele'fli <br /> Manifest Reference Number: <br /> 18b,Ahortlate Facility(or Ca Oh or) U.S-EPA ID Number <br /> V <br /> w Fool Phone: <br /> 190.Signature of Atari Facility or Generelor) Mon01 Pay Year <br /> Z <br /> S2 19.Hatamous Waste Report Management MOM Codes Q.B.,codas for hezartlorls waste Iraarment,disposal.and recycling systems) <br /> 1' M141 <br /> 20.Designated Fadhy Owneror Operator:CeNOratl receipt of hazardous maNrala coverad by the manliest except ea rolad in Item ' <br /> 7n"nIedIrTypei Sgnebae rdonth Day Year <br /> EPA Foorrrm487700--2(27.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />