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SK SHIP# 21949681' ��U II I)I�II i�l�llll�l IIII III I 0 0 5 2 G 5 A 9 3 5 K 5 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator fD Number - :1001O44 2.Page 1 of 3 Emergency Response Phone 4.Manifest Trackin Number WASTE MANIFEST 005254.93 SKS 5.Generators Name and Mailing Address,art 3nagi 14HW Facility Generators Site Address(if different than mailing address) y ':AS.? zA E d St :1N _ CA 95206-000: Generator's Phone: 6.Trarlspgderl Company Name U.S.EPA ID Number TEMS, INC. 7,Transporter2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA, INi_,. U.S.EPA ID Number 681130 SMITH AVE. NEWARK CR 945�tr 51'0--735--440=10 ' CAD98O887418 Facility's Phone: ga 96.U.S.DOT Description(including Proper Shipping Name.Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No- Type Quantity WtNot aoi 3 S LLJ zLLJ 2. 3, 4. d 14.Special Handling Instructions and Additional Information = 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledlplacarded,and are in all respects in proper conditlon for transport according to applicable intemabonal and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of Me attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)lit I am a large quantity generator)or(b)(Bl am a small quantity generator)is true. Generatorsl0herors Pnnted/f ed Name Signature Month Day Year M��hR�G rev/ 1� aa� ,�.Tc y�/r.✓ �% -J 16.International Shipments Z ❑Impart to U.S. ❑Export from LLS. Port of entry)exit: Transporter signature(for exports only): Date leaving LLS.: w 17.Transporter Acknwvledgmentof Receipt of Materials OTransport 1 Printedliyped N -am Signature Month Day Year L i tib Via lid z Train sporter 2 Printedlryped Name Signature Month Day Year rr r 16.Discrepancy 1Sa.Discrepancy Indication Space ❑Quantity W& i `' ❑Type ❑Residue ❑/Partial Rejection 9 C Full Rejection ;1" 6Dp— o �. Manifest Reference Number: O d c� I i 18b.Alternate Facility(or Generator) D U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature ofAttemate Facility(or Generator) Month Day Year zz C7 y 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) i r(1 3 i 2. 3. 4. 20.Designated Facility Orwner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item lag PdnledlTyped NameSignature Mont Day Year EPA Form 8700-22(Rev.,3-105)Previous editionsare o solete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)