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SSL SK SHIP# --0120405 <br />Please print or type. (Form desyned for use on elite (12 -pitch) typewriter.) <br />111111111111111111111111111 IN 11111 <br />005523501 SKS <br />Form Approved. OMB No. 2050-0035 <br />EPr fmi L'4Wifj6kM51 Previoull editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS t. Generator ID Number CRH 111001044-71 <br />'PSWIWIRMUf"M0 <br />'1 haniforstTracking <br />4 1005523501 <br />5 Number um er 01 SKS <br />WASTE MANIFEST <br />' 1 <br />56spanl°ria and ni°odunt -Household Hazardous Wasteenere�pana (urnUhanOmagingaddresgt <br />y y q y ousehold Hazardous <br />1810 E Hazelton Rve 7850 RA Bridgeford Street <br />STOCKTON CA 95205-3939 <br />559-972-7690 STOCKTON <br />CR 95205-0000 <br />Generators Phone <br />a.T901"Vit 0RC'" SYSTEMS, INC. U.S. EPA to Number <br />TXR000081205 <br />7. Tmnsponer 2 Company Name U.S. EPA ID Number <br />B. Designated Facliry Norse and She Address —CALIFORNIA, INC. U.S.EPAIDNumber <br />6880 SMITH AVE. <br />NEWARK CA 94560 <br />510-795-4400 <br />CRD98081FI74i5 <br />Fachl ns Phone. <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Haaam Class. ID Number. <br />10. Containers <br />11, Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantry <br />WINoI <br />13.'Naste Codes <br />No. <br />Type <br />K <br />1(USED OIL) WASTE, <br />TT <br />G <br />221 <br />0 <br />w <br />z <br />2 <br />w <br />3 <br />4 <br />ESU: <br />14. Special Harding Instructions and Additional Information rSD:EV6 <br />24 HR EMERGENCY N1-800-468-1760 (SK / TFI) <br />r.UTH AS "AGENT—FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare mat the contents of this consignment are fully and accurately described above M'the proper shipping now, and are classified, packaged. <br />marked and labeledrpkacamed. and are in all respecasm proper condition for transport according to applicable international and national governmental regulabons. If export shipment <br />and I am the Primary <br />Exporter I pretty that to contams of this consignment conform to the torts of the attached EPAAcinowledgment of Consent. <br />I certify mat he waste mimmucaton statement Identified in 40 CFR 262.271a1(it I am a large quantity generator) or (b) (dl am a small quantity generator) is nue. <br />GeneratoesrOBemrs Pmdedrfyped Name Signature <br />Month Day Ye/cur <br />L- -ea-- <br />Z � /Y <br />J <br />F— <br />16. Imemational Shipments <br />❑Import to U.S. El Export born U'S qrNeey <br />? <br />_ <br />Transpomer signature dor exports only). .a""ea. U5. <br />w <br />17. TrenspWvAckvAedVnMof Recaiplof Matefials <br />Transporter Pnnted7Typed Name r sign atcre <br />Monro Day Year <br />O <br />a <br />N <br />< <br />L <br />QTransporter <br />2 Pm ylxd Name SgnaWre <br />Month Day Year <br />ofr <br />Discrepancy <br />Ito <br />Ise, Discrepancy indication Space ❑ Quantity 1:1 Quantity ❑Residue ❑Partial Rejection <br />❑Fui Rejection <br />Manifest Reference Number <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />Foolery's Phone: <br />w <br />16c. Signature ofAhemate Facility (or Generator) <br />Month Day Year <br />a <br />z <br />19. Hazardous; Waste Report Management Method Codes (i. e., codes for hazzmnus waste troasment. disposal. and recycling systems) <br />0 <br />1. <br />H 03 <br />2. 3. <br />20. Designated Facility Oxer or Operator. Certification of receipt of hazardous matenals covered by the manifest except as noted in Item 18a <br />Pnmedfryped No T �. SignatureMonro <br />Day Year <br />Y <br />2F <br />EPr fmi L'4Wifj6kM51 Previoull editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />