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OCT-27-2008 18:27 CITY OF LODI 209 333 6710 P.36 <br /> Please print or type.(Form designed for use on elite(121Atch •ter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number �7_ 2.Page 1 of 3.Emergency Response Phone 4.Manlleest TISCIdn umberr <br /> WASTE MANIFEST CAF}98".�J2601 F i—t)00-458-1760 0 0 0 9 0 4 7 6 SKS <br /> $.Generalofs Name and MaligAddre l$ Generators She Addreea(if diffMent tan mailing address) <br /> CITY OF 1.01 <br /> 1331 5 HAV LANE P,TTIN ROGER <br /> LODI CA 95240 <br /> Generators Phone: 209-333-6530 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SAFEFV-9LEEN 8Y5TENS, INC. ThFr3+ 0080930 <br /> 7.Traneponor 2 Company Name ........ ... - -- U.S.EPA 10Number <br /> B.Designated Facility Name and Site Address SWETY—KLEEN SYSTE55, INC. 000750 U.S.EPA 10 Number <br /> 5000 SETH MEET <br /> 8ACRAPtE•HT4 CA 95826 CA0000094517 <br /> n6-386-49101 <br /> FaGll 's Pnona: <br /> Bin.US.DOT Description(irdUdI1 Proper Shipping Name,Hazard Bass.ID Number, 10.Comet am 11.Total 12.Unit <br /> 9a. 9 ng 11 Wavle Corns <br /> HIM arld Packing Gmup if any)) No. type Quantity WUVaI. <br /> as X 1HAZARDOUS HA'.1 i LI211IQf. N. Q, S. of G }i0$.9 334 <br /> '9r x44:2092 PC Ill <br /> P .S-" <br /> ECEIVEDL <br /> 3. J,4N _ 4 2003 <br /> d MUNICIPAL S <br /> VICE CES <br /> 14.S*51Harding lnamonsand Additional lnformellon TRCKR1091079334 Gs3n',A344Q 00003707,97-07-5t.. 2S <br /> 1 r •. r e J!3 C S <br /> 15. GENERATOR'SrOFFE &$CERTIFICATION: I heLbyf4wisrs thallhs Contents of this consignment are fully and acaumlely described above by the proper shipping name•and are classified,packaged, <br /> marked and Ishelaelplat'arded,and area,n as fsspecla In Proper canddon for transport according to applicable International and nallonal governmental regulations.If export shipment and I am he Pnmary <br /> Exporter,I cat that the contents Of-JU consignment cantalm to the lam of the attached EPAAOknowledgmantof Consent. <br /> I codify Nal the waste mtnon s <br /> imizat tatem9 identified In 40 CFR 262.27(a)Of I am a large quaMlty ganarator)or(b)Off am a amqs�andly generator)is We. <br /> Genemtors101femrs PrnmdlTy*Name 9gnallxs _ M.(!S Day Year <br /> J 16.Inlemetional ShpmeMs <br /> F ❑Import to US. ❑Export from Part Pan of adrylexlt <br /> =I Transporter Signature(for exports only): Date leaving U.S.: <br /> V,Transporter Acknowledgment of Reoelpl of Materials <br /> Tramponer rinttedrryped Name Signature Month Day Year <br /> 4 14h ) o� S . Acd <br /> ns rtar nn pe ams •.-... MmN Day rear <br /> 18.0iscrepanoy 7. . <br /> 1Ba.DlacSgp?I,!yy,IPe pfiog,$DacE ,.. ❑ Quantity ❑TYPa :.❑Resltlue ❑Partial Naledrr. ❑Full Rejection <br /> Menlrasl Raterence Number. <br /> 18b.Alternate Farilihy(a Generator) 0.$.EPA ID Number <br /> J <br /> C:a <br /> sQr. Paddy's Phare: Month Day Year <br /> W 160. nature of Alternate Fadlty Generator) <br /> 6 <br /> 2 <br /> �C9 19.haEardous Wada Ropon,Management Ma1h0e Codes(I.e.,codes far ha1AMW3 wa9la treatment,413posat and recycling systems) <br /> ` 1 2 3, 4. <br /> 1. 1 <br /> 20.Cealgnalad Facility Ownetof operator.CeNrinkA WPlofhazadousmalefielsmveredbymemandeatexcoplasngedlnitemI a ` <br /> PontediTyped Narneignsurre Mbnm Day Year <br /> EPA Form 8700-22( ev. •05) PreviousedIdonsamobsolete. DESIGNATED FACILITY TO GENERATOR <br /> 1)000G£39 a) 3) 4 <br />