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�3��� IIIIIIIIIII II IIIIIIIIIIIIII 1111111 <br /> SSL SK SHIP# 218916897 <br /> 0 0 5 3 2 9 2 9 4 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 TxR000061z0s 2.Pag9 I—'Number 1 of 3 E 4tr 4.Manifest Tracking Number <br /> Mrf°P�o <br /> WASTE MANIFEST 1 1 005329294 SKS <br /> 5.Generators Name and Mailing Address Genaratots Site Address(it di"'Then meili address) <br /> SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209-545-1011 SALIDA CA 95368 <br /> 6.T a9!�Ia SYSTEMS, INC. U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated FadlRy Name and Site Address SAFETY—KLEEN OF CALIFORNIA, INC. U.S.EPA ID Number <br /> 6860 SMITH AVE. <br /> NEWARK , CA 94560 <br /> CAD980887418 <br /> 510-795-4400 <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)) No. Type Quantity Wt.Nol. <br /> NON RCRA HAZARDOUS WASTE,LIQUID G 133 <br /> C ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) <br /> f- <br /> � <br /> z Z. <br /> W <br /> /7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Intonation TSD:EVG <br /> 24 HR EMERGENCY #1-800-468-1760 (SK f TFI) <br /> RUTH 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 classi5ed,packaged, <br /> marked and labeledliplacarded,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 certify that the contents of this consignment conform to the terms of the attached EPAAcknoaledgment of Con t. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(it l am a large quantity generator)or(b)(if I a s4l quantity generator)is We. <br /> Gene oesr0femes Printed/Lyped Name Signature Month Day /Year <br /> J16. nems onal Shipments <br /> 1- ElImport to U.S. ElExportfrom EU.S. ort of entiylexit: <br /> Transporter signature(for exports only): F Date leavi U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Trans er 1 Pnnted/Typed Name Signature Monde Day Year <br /> H s le <br /> G Transporter PnntedrTyped Name Signature Month Day Year <br /> K <br /> H <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Radial Refection ❑Fuil Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> uta 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 20.De ili y Owner o tion of 6ill hazardous materials covered h n m Item <br /> PnntedFFyped arae SignaNre Month Day Y <br /> /b <br /> EPAFpTm8700-�21Re J 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />