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e-7 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIJillIII <br /> SSL SK SHIP# 218916905 <br /> 0 0 5 3 2 9 3 0 2 5 K 5 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewdler.) p Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.GeneratorlD Number TXR@@@@81205 2.Paget of 3,IEmpr9rRegpppsel /6@ 4.Manifest Trackin Number SKS <br /> WASTE MANIFEST OY.��[' 44tl7 1 /E1 0053 9302 SKS <br /> 5.Generators Nama and Mailing'Sr <br /> Generators Site Address('rf tliaerent then maiki atltlress) <br /> SAFETY-- SYSTEMS, INC. SAFETY—KLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95:68 <br /> Generators Phone: 209-545-1011 SALIDA CA 95368 <br /> 6.T MV-0T ,ttlN SYSTEMS, INC. U.S.EPA ID Number TYR000081207 <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 /> CAD980887418 <br /> 510-795-4400 <br /> Facilgys Phone: <br /> gs 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13 Wavle Codes <br /> HM and Packing Group if any)) No. Type Quantity vim. <br /> 1. NON RCRA HAZARDOUS WASTE,LIQUID TT G 133 <br /> c ETHYLENE GLYCOL SOLUTION (LESS THAN 50x' <br /> Do Irv© <br /> z 2. <br /> W <br /> 3. <br /> 4 <br /> 14,Special Handling Instructions and Additional Information TSD:EVG CSU. <br /> ='4 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'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described shove by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,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 tens of the attached EPA Acknowledgment of Gon nt. <br /> I ceNfy that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(if -n mall quantity generator)is We. <br /> Generato Offerors Pnnted(Typed Name Signature Month Day Year <br /> `-A^4 Ito 10 llo <br /> j16.International Shipments <br /> ❑Import to U.S. El Expon from U.S. If Portof enbylexit: <br /> M Transporter signature(for exports only): DaA leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Trans 1Pnnted/Typed Name Signature Month Day Year <br /> y N dr <br /> QTra oner Pnntedrryped Name Signature Month Day Year <br /> K <br /> H <br /> t18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Reject. ❑Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facility's Phone: <br /> w18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. RL 2. 3. 4. <br /> 20.Designated Facility Ownr or Operator:Certification of receipt of hazardous materials covered by the manifest except as ncled in Item 18a <br /> PnnteWTyped Nama Signature Month Day Year <br /> Ftv � S � <br /> EPAFgEF -ffgW ,3-O5) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />