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SSL " � 1 °J ' ` 411111111111111 VIII IIII II IIII II VIII <br /> 0 0 4 9 3 1 4 5 4 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved_OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAD054598289 2.Pagat of 31Ememancy Raseogse Pl?rre0 4.Wnitest Tnckln Number <br /> WASTE MANIFEST 1 avv—+ibe-1 00491454 SKS <br /> S.Generators Name and Mailing Address Generators Site Address(d different than maiTmg address) <br /> Sanborn Chevrolet <br /> 1210 S Cherokee Ln <br /> Lodi CA 95240-5994 <br /> Generators Phone. S59-479-2632 <br /> 6.TrnsletlarLCoropanµ7�ame SYSTEMS, INC. U.S.EPA ID Number TXROOOOS1205 <br /> 7.Tr`an�sipYortGer12 fComppannyy Namve U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA, INC. U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK CA 94560 <br /> S10-795-4400 CAD980887418 <br /> Facilitys Phone <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, to.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(d any)) No. Type Ouanfily WINO. <br /> NON RCRA HAZARDOUS WASTE 133 <br /> o ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) <br /> o lC) <br /> = 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information b H r:b 02 e01bz!51 <br /> 24 HR EMERGENCY N 800-468-1760(SAFETY—KLEEN) <br /> SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents or this consignment am fully and accurately described above by me proper sfepping name,and are classified,packaged, <br /> marked and labelediplamrded,and are in all respects in proper condition for transport according to appkwe international and national gcvemmental regulatiau.If export shipment and I am the Primary <br /> Exporter.)certify that the contents of this consignment conform to the terms of the arlacted EPAAcknovAedgmenl of Consent. <br /> I certify Viii the vresle mininnaWn statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(dl am a tory generator)is true. <br /> Gene,gucies.10flefs Pnnled/Typed Name Sgna Monty Day Year <br /> .Int Wnal Shrpmen <br /> (..- ❑Import to U.S. EJExporth U.S. Pon of entrylexit <br /> Z Transporter signature(for exports only) Date leaving U.S. <br /> W 17.Transporter Acbgwtedgmem or Receipt of Materials <br /> K Trac r 1 PnnledlTyped Name Signature Month Day Year <br /> N <br /> L J IZ t <br /> Q porter 2 Printed/Typed Name Signature Mond, Day Year <br /> 18. <br /> Discrepancy <br /> 18a.Discrepancy Indication Space ❑o anWy ❑Type ❑Rasidue ❑Partial Reject. ❑Fun Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA 10 Number <br /> J <br /> U <br /> LL Faoiiys Phone: <br /> w18c.Signature of Alternate Fadity(or Generator) Mash Day Year <br /> Q <br /> Z <br /> 19.Haxandous Wart Mnt M <br /> ste Repoanagemeedved Codes(ia,-des tar haouswarardsta treatment disposal,and recycling systems) <br /> Uj <br /> 1. /y/ 2. 3. 4. <br /> 1 20.Designated Facibly Omer or Operator.Gefblicatldrl of receipt of hazardous materials covered by the manifest excepl as noted in Item 18a <br /> Prvttedllyped Name �T / Sgnatum Monty D+Y Year <br /> opu <br /> EPi��m�72���-05)Previous 61ciffim.re.Isdellet. DIESIGKOE6 FACILITY TO DESTINATION STATE(IF REQUIRED, <br /> RECFV ED <br /> MAY 19 2017 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />