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• <br />0 <br />0 <br />Form Approved. OMB No. 2050-4039 <br />ncaao <br />Pnrn V, ryPc. tr-uuuu <br />1. Generator ID Number Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />UNIFORM HAZARDOUS CAL0000689'7212.. <br />WASTE MANIFEST — —,SKS <br />5. Generators Name and Malling Address General SileAddress (if diHerenl than mailing address) <br />ORCHARD H S 05555 <br />2659 NORTH MACARTHUR DRIV TRUCKCSAHg5f3 6REHOUS <br />TRACY <br />GennratoiPhi 244-833-37,90 <br />U.S. EPAID Numb <br />��orp�r�rr� <br />s.raAl' '1Yw!{�L TIe TSR004f]5093r1 <br />SYSTEMS, INC. <br />7. Transposer 2 Company Name U.S. EPA fD Numbor <br />8.0esgnaladFacill lame and Silo Address SAFETY-KLEEN SYSTEMS, INC, 0007(10 U.S,EPA 10NUmber <br />6000 88TH 9,TREET <br />SACRAME14TO CA 95828 <br />CA00000$95J,7 <br />916-386-4913 • <br />I <br />Fadrity's Phone: <br />ga. 9h- U.S. DOT Desrr' Wn (including Proper Shipping Name, Hazard Class, d) Number. 10. Containers It. Total 12, Unit 13. Waste Codes <br />HM . and Faciing Group (1 any)) No. Typo quantity WI.Nol <br />'-NON RCRA HAZARDOUS WASTE,LIQUID <br />GLYCOL SOLUTION (LESS THAN 50%) <br />DM <br />a <br />ETHYLENE <br />z <br />2. <br />w <br />r9 <br />3. <br />4- <br />14.SpeclalHandlingImtnrclionsandAdditxrnallnformation SK TRCK#110520264 0002882503 <br />y <br />1 <br />K AIMOR �T <br />15. GENERAT ii'SfOFFEROR'S RTIFiCATION: I hereby declare that the curtanls al thls consignment azo I and accurately described above i Bre proper shipping name, are) are classified, packaged, <br />to applicable IntemaVonal and nafianal govemmenlal regulations, 11 export shipment and I am the Primary' <br />marked and labelediplacarded, anis are in all respects In proper condition for bansport according <br />Exporter, I cenify that the contents o�ll Gonslgnmenl conform to ft lawns of the attached EPAAcknow[edgment of Consent. <br />I certify that the waste minimization statement idon0hed in 40 CFR 252 27(a) (if I am a large quantity generator} or (l (if 9 am a small quanldy gencraterj Is true. <br />mi <br />G ra goror%Printedffype� r8e S' alure Month Day Year <br />_j <br />er <br />16, Irnernalfonal Stipments o en0ylexil: _ <br />❑ Import to U.S. ❑Ex fbs fro <br />Transporter signature (forexposs onil Bale leaving U.S.: <br />117. <br />TranspoAerA&WY4edgmeni of Receipt of Materials <br />Monh Yea <br />Tra er 1 PriniadrT Hama S n _Day <br />O' <br />`10 <br />z <br />Transpo" Print yped ame Signature Month Day Year <br />Q <br />18. Disc epancy <br />18a. Discrepancy Indication Space ❑ quantity ❑ Type ❑ Rustdue ❑ Partial Rejection ❑ Full Rejection <br />Manilas) Reference Number. <br />18b. ARemato i(or Generator) U.S. EPA 10 Number <br />a <br />u <br />Faality's Phone: Month Ray Year <br />n <br />w. Signature olMiernate Facility (or Generator) <br />19. Hazardous Wasle Report MBnagemenl Mal Codas (i.e.. codes for hazardofas waste Irealment, disposal, end foeyOng Systems) <br />UJ <br />Q <br />I 3. 4. <br />�t141 2. <br />20. designated Fadlily Owner or Operator: Cort rication of receipt of hazardous male lois covered by Ina manifest except a sed in )taro <br />P7rled/3yped ame Si a Month Day Year <br />1TY T� GEf+IERATOR STATE IIF RGiUI EQ <br />�0b'3��f,. 4 ) <br />r <br />