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0 0 5 3 2 9 8 8 5 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 _ 2.Page_1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST T 1005329885 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(K different than mailing address) <br /> g, INC. <br /> _ CA 95368 <br /> Generators Phone SAL IDA <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> INC. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address C - - U.S.EPA ID Number <br /> SAFETY—KLEEN OF CA!_IFQR,NIi?, :. .- <br /> 6:'82 SMITH AVE. <br /> h•1"!A':2�" CA ?4562 <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 <br /> HM and Packing Group(If any)) No. Type Quantity Wt vol. 13.Waste Codes <br /> 1. 1fi'IN—RCRA HAZARDOUS <br /> o (UCFD OIL) <br /> � Qol 31SS <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Intonation <br /> 15. GENERATOR'SIOFFEROR'5CERTIFICATION: I herehydeclare that the contents of this consignment are fully and accurately described above bythe proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplararded,and are in all respects in proper condition for transport according to applicable international nd 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 EPA Acknowledgment of Con at. <br /> I certify that the waste minimuation statement identified in 40 CFR 262.27(a)(KI am a large quantity generator)or(b)(NI m mall quantity generator)is We. <br /> Genem r's•Offerors PnntediTyped Name Signature Month Day Year <br /> 1&7 Z8 I ib <br /> 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. on of entrylexit: <br /> = Transporter signature)for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Trens her 1 Printed(fyped Namq� Signature Month 'Oay Year <br /> N • W <br /> QTransporter Pnntedrryped Name Signature.. Month Day Year <br /> C <br /> H <br /> t18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) LLS.EPA ID Number <br /> J' <br /> LL Factlitys Phone: <br /> w .Signature ofAumate Fal(or Generator) Month Day Year <br /> Q <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 3 2. 3. 4. <br /> jj]Lesignate Owner tion of recoi hazardous materials covered b t as noted in It <br /> Hiram riypedN a SignaNre Month Day Year <br /> are <br /> EPA Fonn 8700-22(Rev.3-DS) Previous edNons are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />