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SSL SK SHIP# 218092541 f`311 111111111111111111111111Jill IIII III <br /> 0 0 5 2 4 4 7 0 9 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number TXR00OO812O5 2.Pagi 3,iFd M04Egse f17ff0 4.Manifest Trac kin Number <br /> GWAASrTTEE MMAyNIFFEESdT�p�p��q�>�� (Ir�ry�r�p 1�p�I O 0 5 c �4709 SKS <br /> S. S V9*2 ttLttWV79 EMS, INC. Generb Ftl Ye .LttlVt `jY`.iltf�l.`i ass)I NC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> 209-545-1011 SALIDA CA 95368 <br /> Generators Phone: <br /> s. <br /> TWpVfqMEtffSYSTEMS, INC. U.S.EPA IO Number TXR0O0081205 <br /> Y <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA, INC. U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK , CA 94560 <br /> Si0-795-4400 GAD98O887418 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No Type Quantity Wt.Nol. <br /> 1- NON RCRA HAZARDOUS <br /> K ETHYLENE GLYCOL SOLUTION' G 133 <br /> 0 (LESS THAN 50X) <br /> ga OD <br /> z 2. <br /> W <br /> c� <br /> 3, <br /> 4. <br /> 74—Special Handling Instructions and Additional Information 1 <br /> ., 4 HR EMERGENCY #1-800-468-1760 (SK / TFI) <br /> AUTH AS "AGENT—FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabdedlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulators.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment ofsent. 11 <br /> I certly that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)cam,ojiiiiaii quantity generator)is true. <br /> Gener loesierors Printedfryped Name Signature Month Day Year <br /> 1 ` o7 IM6 1 16 <br /> Jntem anal Shipments <br /> _ ElIImport to U.S. ❑Export from U.S. Port of entry/exiC <br /> Transporter signature(for exports only)'. Dateleavin U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporte 1 PnntedRyped Name Signature Month Day Year <br /> oa (�OA4 07 1 ZB <br /> N <br /> Q Transporter PrintedRyped Name Signature Monty Day Year <br /> K <br /> i18.Discrepancy <br /> 18a.Discrepancy Indication Space ElQuantiy ❑Type 11Residue ❑PaNal Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rai Facility's Phone. <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> zz <br /> y19.Hazardous Waste Report Management Method Codes F e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2, 3. 4. <br /> 2 ed Facility Owner or tion of race of hazardous malenals covered by the ma t as nded in Item 1 <br /> 1 Pnnted7Typed Signatu a Month Day Year <br /> Kar <br /> ptt �--OS) <br /> Previous editions are obsolete. DESIGNATED FACILIT TO DESTINATION STATE(IF REQUIRED) <br />