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SSL SK SHIP# 214383310 <br />Please print ar 1ppe. (Poon designed for use on elite (12-pildi) typewriter. ) <br />Form Approved. OMR No. 205HO39 <br />EPAForm5700-22Rev.105 Previous editions are obsolete. <br />1)11249/ 5601 <br />DESIGNATED FACILITYTO DESTINATION STATE (IF REQUIRED) <br />f <br />r <br />UNIFORM HAZARDOUS 1. Damsel" ID Nomber <br />CAHi 11001044 <br />2.Pagelol <br />1 <br />3Em"enc Re ePlane <br />1—�0�-48-1760 <br />O. Manifest Tacking Number <br />SKS <br />WASTE MANIFEST <br />1004495298 <br />5. Danamtors Name and Malling Address Concretes Sae Address (if different Nen mailing address) <br />Ban Joaquin County Public Works Solid Waste Div <br />7850 R R Bridgeford St <br />Stockton CA 95206-3939 <br />Generators Phone: 559-972-7690 <br />eTrYRFFTY(t tM SYSTEMS, INC. U.S.FPAlONumber TXR000081205 <br />T Transp"ar 2C"npany Name U.S. EPA IO Numeer <br />B DesignaloU Feo6ty NameeM SNa Address SAFETY—KLEEN OF CALIFORNIA, INC. U.S,EPAIDNumber <br />6860 SMITH AVE. <br />NEWARK CA 94560 <br />510-795-4400 CAD980807410 <br />Peak Is Pham: <br />ga. <br />9b_ U.S. DOT Descdplbn (moludirg Proper Shlpphg Name, Hazard Class, ID Number, <br />10. Cents <br />11. Taal <br />12. Unit <br />13. Waste Codas <br />No. <br />Type <br />11M <br />and Peckig GreoP (ff ally)) <br />Quanti <br />LNd.ty W <br />m <br />1. NON—RCRA HAZARDOUS WASTE, LIQUID <br />TT <br />G <br />221 <br />— <br />o <br />(USED OIL) <br />� <br />ar3� <br />Slo <br />w <br />2 <br />3. <br />TAI. <br />HEA1T!4r1c"Au <br />arkrt <br />14.9peeu!klaMeng lnstruXais and i+xlm lnWematWn TSD:EVG 65092747 SA33073 CSG: <br />24 HR EMERGENCY #1-800-468-1760 {SAFETY—KLEEN) <br />15. GENERATOR'SfOFFEROWS CERTIFICATION: I herehy declare that the contents ofthIs consignment are fitly and aCcuralelydescribod above by The propershipping name, and are classified, packaged, <br />marked and lik etedrplacarded, and we in at respecb in proper condition for banspoitaccardirg aappleahle international and national govemmenlal regulations Il ezpor(shiparenl and l am tM Primary <br />Exporter, I certiythal the contents of this consgri conform to the terms of me attached EPAAcknowdeel l of Coment. <br />I caddy than the waste min eezallan statement Identified In 40 CFR 282.21(a) (if I am a large quell generatur) or (b) (ii I am a small quantity generaa) Is Ione. <br />Sgwwe Month Yew <br />Oerwrabrs'Offames Pdnsidi?yped Name``� <br />�Daay <br />��ss�� <br />�.l Vote ST2nJDLL <br />N/ L Lt.+_s`�.b.Lctifo <br />1 Ine+rallorW 9h'gmxmts❑J Impotl 1p 4$. �F�IPan koro U.S. PaM1olaneylexa; <br />Tfan4F9(IPl signa!uM (for expos any). Dak leaving U.S.' <br />17 Transporter Acknowledgment of Remipt of Matelots <br />TM 1 Pdnte rryped Name signat"e Month Day Year <br />O <br />yz <br />o lil <br />6 <br />r poner2P ntedRyped Namo Slgnalme oath Day Y& <br />18. onerupancy <br />18a. Discrepancy lndirallon Space ❑ Quantity ❑Type ❑Residue ❑ Padzl Rejection ❑Full Rejection <br />Manifest Reference Number. <br />18b. Alienate PaUity (or General") U.S. EPAID Number <br />V <br />LL <br />Peelle" Mone'. <br />w <br />18c. SignaWre ol'Abereate Facility for Generator <br />Month Day Year <br />a <br />ME <br />m19. <br />Hazardous Waste Report Management Mebad Codes(ie., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. <br />J b� <br />4. <br />20. DasMarreted Facility Owner or Opemlm: Carnival ofrecalpl ofhazerdous matelots covered by the manifest exmpla dad In <br />PahW7yped Na <br />Slgnarom Month Day Year <br />t'p c P' 110 114 <br />EPAForm5700-22Rev.105 Previous editions are obsolete. <br />1)11249/ 5601 <br />DESIGNATED FACILITYTO DESTINATION STATE (IF REQUIRED) <br />f <br />r <br />