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4 <br />{ <br />Plp —p.. nrmt or tvnp.- f Fnrm dpginnp4l for nSP. on P.IItp. 11 1 tvnawritr,r I <br />0 <br />l-nrm Annrnvarl nVIR Nin 9nFfl_nngci <br />" <br />UNIFORM HAZARDOUS <br />1. Generator ID Number - <br />������� � � �� � <br />2. Pae 1 of <br />g <br />3. Emergency Response Phone <br />9 y p <br />4, Manifest TrackingNumber <br />001 4218 SKS <br />WASTE MANIFEST <br />5 <br />1-800-468-}760 <br />6. Generator's Name and MailipnpggG Address Generator's Site Address (if different than mailing address) <br />2650 NORTH MACARTHUR LRIV TRUCK SHOP WAREHOU' <br />TRhcy CP 95376 <br />Generator's Phone: 209-833-3190 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />SAFETY-RLEEN SYSTEMS, INC, <br />TXPOOD050930 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />' ' 3 ? C! ; moi <br />{ <br />,Y- <br />8. Designated Facility Name and Site Address 'ZAF .TY--PLEEN SYSTEMS, INC oim1,8 U..EPA IDNumber <br />17.22 COOPER CREEK ROAD <br />DC14TO , TX 76208 <br />940-483.5200 <br />TXD0776033 11 <br />Facility's Phone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />W1.Nol. <br />X <br />1RQ WASTE €'LA11KABLE LIQUIDS, 14. O. S. <br />DM <br />P <br />D001 <br />D008 <br />17018 <br />tii1993 t�C 71 ! Lti01.#3, [70UI r <br />213 <br />OUTS <br />LU <br />z <br />2. <br />W <br />0 <br />3. <br />4. <br />14. Special Handling Instructions and Additionat Information . 1( TRC K* 109 4 3 2 6 6 7 0002882503 <br />I)ERG*128 <br />Sk AUTH'D TO USE S'UBSE UE14T CARUIERS:41078 43471 81681 82739 35399 <br />15. GENERATOR'SIQFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classed, packaged, <br />marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable intematicnal and national governmental regulations. If export shipment <br />and I am the Primary <br />Exporter; I certify that the contents of this consignment conform to the terns of the attached EPAAcknoWedgmeni of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (0 I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />GeneratoeslOfferoes Printed/Typed N m Signature/ ] <br />Month Day Year <br />r <br />I- <br />16. Internatiatial Shipments <br />❑Import to U.S. ❑ Export from U.S. Port of entrylekif: <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />LW <br />17. Transporter Acknowledgment of Receipl of Materials <br />W <br />Transporter 1 PrintedrTyped Name Signa <br />Month Day Year <br />0- <br />�'" �' <br />ZZ <br />Transporter�2'�Pririnntli 3Wyped Name Sign [Pre m <br />Month Day Yeg� r <br />/ .fes`• <br />l C <br />4 ./Cxr t ! <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection <br />❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) US. EPA ID Number <br />U <br />LL <br />Facil Vs Phone: <br />w-11 <br />18c. Signature ofAltemate Faciti(y (or Generator) <br />Day Year <br />a <br />7orth <br />z <br />S2 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />f <br />20. Desig aced Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ed in Item 18a <br />Pn�ypecl Name Signatu <br />Month Day Year <br />EPA Vorm 8700-22 (Rev. -05) Previous ediVons are obsolele. DESIGNATED FACILITY TO GENERATOR <br />) ?005846 2) ,. t 4) <br />1?21;46380/369498--9216 <br />