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SSL bK ,S�IP J--' 1�26JJ 1 - I I I 0 0 4 9 3 1 4 5 4 S K S Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator ID Number CAD054598289 2.Pag t of 3 Em _ 4.Manifest TracidNumber (��/ WASTE MANIFEST � 12m" mgo 004911454 SKS 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) Sanborn Chevrolet 1210 S Cherokee Ln Lodi CA 9240-5994 Generators Phone: S59-479-2632 6.TWHttyfoW&R SYSTEMS, INC. U.S.EPA ID Number TXR000081205 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA, INC. U.S.EPA ID Number 6880 SMITH AVE. NEWARK CA 94560 510-795-4400 CAD980887418 Facilitys Phone: 9a. 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)) 13.Waste Codes No. Type Quantity WINoI. 1' G 133 IX ETHYLENE GLYCOL SOLUTION THAN 50 ) 0 2 0 I C) W Cil 3. 4. ENV i ONS na: - 14.Special Handling lnstructonsand Additional Information b R rrb ,� b ', ' 24 HR EMERGENCY 0 800-466-1760(SAFETY—KLEEN) SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY 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 labeled/placarded,and are in all respects in proper condition for transport according to apphcabfe international and national governmental regulations.if export shipment and I am the Primary Expon .l 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)(l I am a m ntity generator)is true. Gene toes/Offero s Printed/Typed Name Signa Month Day Year -� I 1 I —j .Int ational Shipments Z ❑Import to U.S. ❑Export ftL U.S. Por of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17.TransporterAcknowledgment of Receipt of Materials O Trans er 1 PrinledlTyped Name � Signature Month Day Year Qa / ' r Z ransporter 2 Printed7Typed Name Signature Month Day Year H 18-Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q - Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyding systems) 01. 2. r . 4- I20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item taa Printed/Typed Name Signature Month Day Year — EPA%Sj7' &5&05) Previous ibons are obsolete- DESIG09FACILI=TV TO DESTINATION STATE(IF REQUIRED)