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SSL SK SHIP# 218092543 1111111 111111111p1111p11INIII <br /> D D <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 TXROOOOS12205 2.Paggl of 3.1EbbSV"Egg1pS0 4.Manifest Tac kin Number <br /> WASTTEE�MMyA�NIFES�T,y�yp�g q�d�� r p��py� �rfy�r�� 0y0�5 iLl SKS <br /> S. bHFt I Ym"1{�.tt`IV 71 EMS, INC. Gene bWt l Y—AEM,Wftges`I INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209-545-1011 SALIDA CA 95368 <br /> 6.TM W"Ef SYSTEMS, INC. U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Fadliiy Name and Site Address SAFETY—KLEEN OF CALIFORNIA, INC. U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK , CA 94560 510-795-4400 CRD980887418 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt.Nol. <br /> 1- NUN RCRATT <br /> 0 ETHYLENE GLYCOL SOLUTION' G 133 <br /> (LESS THAN 50%) <br /> Z 2. <br /> W <br /> W <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Information 1 <br /> 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) <br /> RUTH AS "AGENT—FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <br /> 15. GENERATOR'S/OFFEROR'SCERTIFICATION: I herebydedam that the contents of this consignment are Polly and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for tmnsport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cerry,that the contents of this consignment conform to the tenors of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I a indquanifty generator)is We. <br /> GeneatorslORero s Pnntedlfyped Name _ Signature Month Day Year <br /> f )10 <br /> 16.International Shipments <br /> i ❑Import to U.5. ❑Export from U.S. ortof entrylexit: <br /> Transporter signature(far exports only): Date leaving U.S.: <br /> w 17.TansporterAcknowledgment of Receipt of Materials <br /> OTransported rintetl/fyped Name Signature Month Day Year <br /> QTransporter 2 Pnnted(fyped Name Signature Month Day Yea <br /> C <br /> F <br /> ♦ 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejecton <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> 6 <br /> z <br /> LD 19.Hazardous Waste Report Management Method Codes lie.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1' //7/ 2 3. 4. <br /> s <br /> edlity Owner o perator:C tion of re of hazardous materials comanifest except a 1 <br /> Printed(fyped NameSignature Month Day Year <br /> o� .z1 <br /> EPP �� �-OS) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />