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07/13/2011 06:29 2095453 SAFETY KLEEN . PAGE 02/09 <br /> 714y <br /> r <br /> 'PIeON!01 or hvir. Form d881 o/d for life on elite 12 Ileh Eller. FormA proved.OMB No.2050•D039 <br /> UNIFORMKAIARDOU5 1.OWomrorONumxr 2.Pepe(of 9.Em OnOy Ru neo Ppeno 4.Man s1 Tre Ino umbo <br /> YEMANIFEBT CAO'161675093 002407561 SKS <br /> 1.0enerallon Name and M laing Abdmi Genchi Sim Addiss Of dl0erml then mailing addmsn) <br /> SAM JOAQUIN REOIQIfAL TRANSIT D SAH JOAQUIN REGIONAL TRAN31T 0 <br /> PO BOX 201010 1533 E LINDSAY ST <br /> 6 Ocill CA ?S.01 ATItI TfiAN5:t7 O:ISTkICT <br /> Goneraloes Pismo X119-948-5566 STOCKTON CA 957.05 <br /> 6.Tenn;oder 1 Com en Nnma U.S.EPAIDNIrmeer <br /> SAFETY• 11L�EN SYSTEMS, INC. TXROOOOS09. <br /> 7.Trommodel T COMPOny Name US EPA 10 Numher <br /> A,DestrofirdFaceyhe"IndSilo Address SAFETY—KLEEN SYSTEMS, INC. u§`{PpiONumoor <br /> 6000 BOTH STREET <br /> SACRAMENTO CA 998:8 <br /> 916-396-4913 CA0000084S17 <br /> Fack In Firms I <br /> go, ImU.S.DOT Nwripl.ongOdutlingPropniSNpping NMI.IdeLBO CIaes.IONummr. 10,Conlalm6 11.70101 aUNr 12 Wools Codes <br /> NM Ord PnsXing Groep(Il any)) N0. Type Quantity WUJaI. <br /> 0 11(AQUEOUS PARTS DU SHEROUIS BSOLUTION)TE, LIQUID OM C 134 <br /> �u 2. <br /> g. <br /> a. <br /> fn.�pateutndllrpbdmdlmsnndndaiNopol,lNomaldn CK GHIPR2o17,i .51IS8940 371161 , 1 201027 CSG:24 <br /> ct, <br /> 24 HR •EMEROENCY 41-600-468-1760 (SAFETY—KLEEN —. 94138) <br /> 19, GENERATOR'BIOFFEROR'S CERTIFICATION: I hereby dollen Net NO mnfanteof l01sW0slgrmoral am fully and eplUralNy dnsdmbed OWN by PB properehipping memo,aid are drmslped,ped7gAU, <br /> morliodand IoboledlplamNM,and Oman a0tamede In pmper wMl"for transporta000wingbdpplblNeINemaeonalend 11111X0101gMITIn rIA Iegulelbn;,if mibm aAlpmeotend am me Family <br /> 5rporrer,I milk that the centers d mIe WnsiGnmenl oonbrm bibs farm;Ot7lie ama&M EPAAdmwdMgmonl of Censer. <br /> I comity thel the waste minambaoen jamemmem benlined In 46 CFR 2112 27(11)Of I am a bilge gurndy 60000101)Is,(h)IMI em a small rluenliy go Wmbr)to Inre. <br /> GmcrabTY06oroya Ponldomped Name Soma Monln D Year, <br /> —a 16.I1110 PbaNl BAlpmmlln II--�—I ' <br /> 1�I lipoma U.9. ❑0apem hoes U.9. PodOfenuy7euf.T„ <br /> TionsPothi fignatum(lot vDIM MY): DAN leaving U.S.' ' <br /> 17.TrnespomOM x2rLIMAl of Ipl of Mahetell <br /> y. Tranepomert pi, y Nemo `� / 5 alum Month Soy Year <br /> �. <br /> renspmrin 2 PrintName Slgnnlroe Ii Day Yost <br /> 1e.0iaeropmey I t jr <br /> 16s.Discrepancy lndmaen Spam Cl Oamay El Pipe ❑Rosldun r ❑padlol Rp cdbn ❑Full ReleMan <br /> Manifest ReN mbar. <br /> Mr.A116=10 Fod1fly,for Coneni S,EPAIDNember <br /> v <br /> G� Fadllye Phomo: <br /> 1ec.SIOM(UNCf AllamNp Fedlylor(dommlM) ` Month Day Yoe( <br /> a <br /> 2 <br /> '19;H,Ardnd Wells Repel ManagelnMl MaObUCMep p.a.,mded brawlber®.aale haetinenl,dhpoml.aM nrydlrq eymemy <br /> T. <br /> / <br /> p0.Deslgm rem N0dF00(yownererOWTalemCaMamaunofreceipt ofAaferrtcusmeledahmroredbymeiwa mmol In Item lea <br /> P <br /> are Signe m Mont Day Year <br /> M <br /> J Gam-- <br /> EPA Polar 87002.2(Rev.3-OS� Previous erel'ons are obaolele. VIESIGNATEDFACILITY TO GENERATOR STATE(IF REQUIRED)' <br /> 1)14941/150135 <br />