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SSL SK SHIP# L--/78976 <br />Please print or type. (Form designed forum on elite (12-Dhch) Ncewdter.) <br />IIIIIIIIIIIIIIHIIIIIilllllllllllllll <br />0 0 4 2 9 5 2 6 3 S K S <br />Form Aoomved. OMB No. 2050-0039 <br />EPA Fo=00-22 (Rev. 3.05) PFMus editions are obsolete. <br />1)651/150163 <br />DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 W <br />3. Emergency Response Prone <br />4. Maneeat Trading Number <br />WASTE MANIFEST CAHI I I 001044 <br />1 <br />1-800-468-1760 <br />004298263 SKS <br />S. GeneralWs Name and Meiling Address Gena stors Site Address (if cifferent than mailing address) <br />San Joaquin County Public Works Solid Waste Div <br />7850 R A Bridgeford St <br />Stockton CA 95206-3939 <br />Generators Phone: 209-468-3066 <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />SAFETY-KLEEN SYSTEMS, INC. <br />TXROOOO8120S <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and She Address SAFETY-KLEEN OF CALIFORNIA, INC. <br />U.S. EPA ID Number <br />6880 SMITH AVE. <br />NEWARK CA 94560 <br />510-795-4400 <br />CAD980887418 <br />Facility's Plane: <br />9e. <br />9b. US. DOT Description (Including Proper Shipping Name Hazed Class, ID Number, <br />10. Cormaitem <br />11. Total <br />12. Unit <br />13 Waste Codes <br />No. <br />Type <br />HM <br />and Padding Group (if any)) <br />Quantity <br />WWW. <br />c <br />NON RCRA HAZARDOUS WASTE,LIQUIDCV.T�% ��� <br />TT0 <br />ate' <br />Z <br />2 <br />2, <br />W <br />3. <br />4. <br />.r <br />14. Special Handling Instructions and Additional ldamation TSD:EVG 63433375 SA33073 <br />201417 C56:60 <br />24 HR EMERGENCY N 800-460-176O(SAFETY-KLEEN - 94138) <br />15. GENERATOR'S(WEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described some by the proper shipping name, and are dassil packaged, <br />marked and labeledlplacaded, 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 <br />Exporter, I cenRy, that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Convert. <br />I cerdy that the waste minlmUaaon statement dendfied In 40 CFR 252.27(a) in I am a large quantity generator) or (b) (81 am a small quantity, generator) is We. <br />GeneraroryOBerors qmAidayped Name signs <br />Month Day Year <br />\ <br />f J _ <br />F1 <br />e'o <br />.IMnalSMpmeds ❑ Import toU.S. 1 LJ Export from U.S. Port of entrylexi <br />z <br />Transporter signature (for exports only)'. Date leaving U.S.. <br />17. TransporterAcknovdadgmeni W Receipt of Mail <br />CTran <br />r 1 Pit ledlTyped Nam a Signature <br />Month Day Year <br />a <br />2 <br />Triffri 2 Fronted/Typed Name SignaWre <br />[7Z 111O <br />Mon Day Veer <br />18. Discrepancy, <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue <br />lam' <br />❑ Partial Rejection I/J Full Rejection <br />R4L)eAa .via <br />sfsbf-T313j4k4- <br />y L 1 <br />E(,1 rqu o. pF (s) k C'61Ofj-" Manifest Reference Number. <br />18b. Alternate Facility (or Generator) <br />U.S. FPA 10 Number <br />J <br />V <br />Facililys Phoma: <br />1 Bc. Signature e( Alternate, Facility, (or Generator) <br />Month Day Year <br />QW <br />2 <br />N19, <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />2, 3. <br />4. <br />20. Designated Facility Owner or Operator Certification of receipt of hazardous mater als covered by the maniksl except as noted in Item 18a <br />1 <br />ypbe Nam sil <br />61j <br />Month Day Year <br />lZ S !v <br />EPA Fo=00-22 (Rev. 3.05) PFMus editions are obsolete. <br />1)651/150163 <br />DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />