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SSL SK SHIP4 214773375 <br />Please adnt or tvae. (Farm designed for use on aide (12�phchl tvoevrtitecl <br />�'1y� 11111111111111 11111111111111111111111 <br />004612362 s NS <br />Form Approved, OMB No. 2050-0039 <br />EPA Form 0700-22(Rev.3-05) Provlous editions are obsolete. <br />1)651/156030 <br />DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page lot <br />3. Emeryency Respansa Phom <br />Minded Trxatrg Number <br />WASTE MANIFEST CAH111001044 <br />1 <br />1-800-468-1760 <br />04612362 <br />SKS <br />5, Generator's Name and Mailing Address Generelays She Address (if dieerem than malting address) <br />San Joaqquin County PUbliC Works Solid Waste Div <br />7850 R A 8ridgeford St <br />Stockton CA 95206-3939 <br />Genendoes Phone: 559-972-7690 <br />6. TnnspoMr 1Canpany Nam <br />U.S. EPA ID Number <br />SAFETY-KLEEN SYSTEMS, INC. <br />TXROOOOS120S <br />7. Tmmpomr 2 canwro Name <br />U.S. EDA 10 Number <br />8 Designated Faohly Name and She Address SAFETY-KLEEN OF CALIFORNIA, INC. <br />U.S. EPA ID Number <br />6880 SMITH AVE. <br />NEWARK CA 94560 <br />510-79S-4400 <br />CAD980887418 <br />Faok sPhom: <br />go. <br />9b. US. DOT Description(ncluding Proper Shipping Name, Hazard Class, IO Number. <br />10 Containers <br />1t. Total <br />12.Unt <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Paddyg Gmha(Kany)) <br />Quantity <br />AlloI, <br />z <br />1'NON RCRA HAZARDOUS WASTE, L1OUI0 O>ti ! <br />G <br />;Z21 <br />50%)Q!:� <br />z <br />2. <br />w <br />r, <br />3. <br />4, <br />NV <br />TA <br />IqF <br />TIJ 5QTn R1T <br />14. Special Handing mswcaons amlAMRonal htcmnatlon TSU: EVG 65512209 SA33070 201451 CSG:60 <br />24 HR EMERGENCY H 800-468-1760(SAFETY•-KLEEN — 94138) <br />15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare dust the contends arms comigumnl are halyand aaurmey described above by ere pass, shipping name, and are cassRed. Packaged, <br />marked and abeledlplacarded, and are In all respells N proper condition for vsnspod according a applicable Inamaaonaland national govemnrenlal mguiatbm. reason shipment and I am mo Primary <br />IbWw,, I certify that the conlan15 of this consgnmend conform to the arms of the attached EPAAcknowledgmeni of Consent <br />I [edify that the waste minbni alion statemnl Identified In 40 CFR 26227(a) (if I am alorge ward0y, genemor) ar (b) (III am a small quantity gamraar)'s (me. <br />GemraloyslO6emi Pdntearypdd Nang Sgnebae - <br />Mon% Day Year <br />�. <br />1151& <br />76 Interco b mi Shlanara ❑ Import to US 10 LjExpDdkomU.S, Pod of antryledt. <br />Iramporlef signature bar emods only): Data keWng U.S.: <br />17. TrenspeMnAbo wledgment of Reveal of Materals <br />inM el 1 In adRyped Name Sgnaare <br />Monro Day Year <br />g <br />U �.1 <br />it r <br />Tmns;odar 2 PnmodiTypod Noma Sgn <br />Mlanih Day Year <br />Is. Dlsaepaxy <br />I <br />16a. Discrepancy Indication Spam E)oany, ❑� ❑Residue <br />❑Panel Rascal. <br />❑FM Rejection <br />MaMest Reference Number. <br />18b, Alienate Facility (or Gemretor) <br />uS. EPA m Number <br />U <br />W <br />r2Hilyre Prairie: <br />Ir <br />z <br />fee Sgnalumcf Allemaa FadMy(o Genemtor <br />Month Day Year <br />19 Hazardous Waste Report Management Method Codes 0 a., codes for haaardous waste lreaimenl, disposal. and recycling eysams) <br />O <br />1. <br />�(3 n <br />3. 2. <br />4. <br />20. Dearin ited Facility Owmr or Opnelar. Certification of receipt of maadous materials covered by tie manifest except as home In hem 180 <br />Pdntxfryped Nam Signature`� <br />f>� <br />_ <br />an Day Year <br />/S <br />EPA Form 0700-22(Rev.3-05) Provlous editions are obsolete. <br />1)651/156030 <br />DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />