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SK SHIP4 21926712 �f Please print or Wile. (Form deSinnad fnr i tca nn alit. /I9_ ;fa kl ti, ,.. a , inn uv -cc nev.,wa! rravruus eumuns are oosole'a. rF DESIGNATED FACILITY TO GENERATOR 1)651'/15 030 - - '11'11' 11-111-"'' Form Approved. OMB No. 2050-003 UNIFORM HAZARDOUS 1. Generator ID Number 2, Pace 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST :'Ai 1,1--468-1760 r �� ,kr_9A''ct' V SKS- 5. Generator's Name and Mailing Address Generator s Site Address (if different than mailing address) Sanborn Chevrolet 1210 S Cherokee Ln LODI CA 95240-5994 Generator's Phone: 59-479-263 ' Pg, 6. Transporter 1 Company Name `' SAFETY—KLEEN SYSTEMS INC 7. Transporter 2 Company Name U.S. @ umper , J 6 r 8. Designated Facility Name and Site Address {�`�� SAFETY—KLEEN Gr (CALIFORNIA 58$0 SMITH AVE. L- S 10-795-44�tQ+ NEWARK , CA 94560 510 -795-44017,11 Facility's Phone: CAD989887.4.18 ge. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) quantity WLNol. 13, Wade Codes No. Type 0 1' NON RCRA HAZARDOUS WASTE,LIQUID G 133 0 _THYLENE GLYCAL SOLUTION (LESS THAN 50%) + U-1 w 2 4. i 14. Special Handling Instructions and Addibonal Information }� TSRsEV6 �A �are►a 24 HR EMERGENCY 41--800-468-1760 (SK / TFI) 15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name. aid are classified, packaged, marked and labeled/placarded. and are in all respects in proper condition for transport according to applicable international 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 the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Z—eneratqrsJOfferoe PrintedlTy ame Signature < r Month Day Year ee'a'WR —J t— 116. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: w 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Rrintedrryped Name . Signature %'";' Month Day Year i O d , c ZZ Transporter PilliTeciffyPed Name Signature Monlh pay Year t- 18. Discrepancy 18a. Discrepancy Indication Space Quantity 1:1 Type El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b. Alternate Facility Generator) (or U.S. EPA ID Number C U. Facility's Phone: w 18c. Signature ofAltemate Facility (or Generator) Month Day Year Q Z ro19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) p1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedrTyped Name !I_ ! Signature Month Day Year i inn uv -cc nev.,wa! rravruus eumuns are oosole'a. rF DESIGNATED FACILITY TO GENERATOR 1)651'/15 030