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SK SHTP# c:Alf `i-, 1 <br />Pleaen odnt mr cone (Form desinned for use nn elite (1241chl tvnervvnter.) <br />1111111111111111111111111111111111111 <br />005245491 SKS <br />Form Approved. OMB No. 2050-0039 <br />EPgFgT 8708-22,(@ai Previous editions are obsolete. DESIGNATESfACILITY TO DESTINATION STATE (IF NEO11,111i <br />UNIFORM HAZARDOUS <br />I Generator ID Number <br />2 Page l of <br />3. Emergency Response Phone <br />4. ManifesttTTrackln/,QI N[uumb/w (� 1 <br />O O 5 Z 4 91 <br />�(c <br />SKS <br />WASTE MANIFEST <br />Y <br />J <br />5 Generators Name and Mailing Address Generators Site Address (d Mthemal man mailing address) <br />HHW Facility <br />St <br />CA 35.. . <br />GenereWrs Phone. -106 <br />6. Tra pi. I Gopvpensnje - U.S. EPA ID Number <br />r_t,- 1NC. <br />r _ <br />Cl <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Facility Name and Site Address SAFETY-KLEFN OF C a! _ i F U"•'•! ; i t i l'dU . U.S. EPA ID Number <br />6A8O SMTTH aVF. <br />^nD9RP�' <br />Fadtiys Phone: <br />ga. <br />Sb. U.S. DOT Description (including Proper Shipping Name Hazard Class, ID Number. <br />10 Containers <br />11 Total <br />12. Unt <br />13 Waste Codes <br />No <br />Type <br />HM <br />and Felling Group (darry)) <br />Quantity <br />Wt.Nor <br />1. NON-PrRA HAZARDI WAST; I <br />o <br />.IS <br />!USED OIL) <br />- <br />DDII4 <br />v <br />Z <br />2 <br />3 <br />4. <br />14 Special Handling InMcdorm and Addibonal Information - - <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare mat the contents of this consignment am fully and accurately described above by the proper shipping name, and are dastufied, pideaged, <br />marsed and Labeled/placarded. and are in all respects in proper condition for transport according to applicable intemabooel and national govemmental regulations. If export shipment and I am the Primary <br />Exporter, I cenrty mat the contents of this consignment conform to the terms of the attached EPAAcknowledgmenl of Consent. <br />I mr* that the waste minimization statement identified in 40 CFR 262.27(8) (d I am a Large quantity generator) a (b) (itI am a small quantity generator) is true <br />GermmWrsr0lferors Pnn yped Name Or Q p Signature <br />Month <br />Day '!ear <br />L 1 —G_ <br />/f c, <br />F— <br />15. International Shipments <br />❑ Import W U.S. Export from U.S. Port d9t1ymXjL <br />1./to <br />_ <br />Z <br />Transporter sfmature)for exports only): Dab leaving U.S.: <br />w <br />17. TranspoMrPdmawledgnenl of Receipt of Materials <br />Trans t PrntedfT pad Name Signature <br />Month <br />Day Year <br />mQ <br />Transporter 2 PrintedlTyped Name Signature <br />Month <br />Day Year <br />K <br />r <br />18 Owepancy <br />18a. Discrepancy indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Retec ion <br />❑ <br />Full Rejection <br />Manifest Reference Nuri <br />tab. Anemate Facility (or GewraWrl US EPA ID Number <br />J <br />u <br />u,Fadlny's <br />Pnane: <br />w <br />1&. Signature o(ARemate Family (or Generator) <br />Month <br />Day Year <br />Q <br />2 <br />h1B <br />Hazardous Waste Report Management Method Cada (i e.. codes for hazardous wash treatment. disposal, and recycling systems) <br />Qor <br />20. Designated Facility Ovmer, Operator Confiscation of receipt of hazardous materials maimed by the manliest except as noted in Imm Ise <br />Pn yped Name Signature <br />Month <br />Day Year <br />I�- <br />EPgFgT 8708-22,(@ai Previous editions are obsolete. DESIGNATESfACILITY TO DESTINATION STATE (IF NEO11,111i <br />