Laserfiche WebLink
SSL SK SHIP# 219566169 8311/ 111111111111111111111111111111111111111111111 <br /> 0 0 5 5 2 2 5 3 6 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.Page11 of 3.€m W R4�se jhjS0 4.Manifest Tracking Number <br /> WASTE MANIFEST -DiC O000g1VO S1005522536 SKS <br /> Genem / d e ff t n it ri a ress) <br /> STEMS, INC. �f����lf—�tt��1�tEl��, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209-545-1011 SALIDA CA 95368 <br /> 1TrS!'flrjFtgQaRLnt!t'Rf SYSTEMS, INC. US EPA ID Number TXR000081205 <br /> 7.Transporter 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 /> 510-795-4400 CAD980887418 <br /> Facility's Phone: <br /> 9a 91b.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 WLN013.Waste Codes <br /> 1. <br /> — E, LIQUID TT G 221 <br /> (USED OIL) <br /> ool �5�1 <br /> z 2 <br /> W <br /> 3, <br /> 4, <br /> 14.Special Handling Instructions and Additional Information TSD:EVG SAL CSG: <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'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,add 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 teems 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 am a small quantity generator)is true. <br /> enItoeslolfero s Pn tl/Typel Name ignature Month <br /> Day Year <br /> 1Y11 V 1 10511(. <br /> 16.Internnal bre pmen s <br /> i1:1Import to U.S. ❑Export from U.S. Pod of entry/exit: <br /> Transporter signature(for exports only(: Date leaving U.S.: <br /> w 17 Transporter Acknowledgment of Receipt of Materials <br /> T nsporter 1 dntedrT ped me nature Month Day Year <br /> y <br /> nl ffl OS /G <br /> QTransporter PdntedRyped Name Signature Month Day Year <br /> K <br /> H <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type y El Residue El Partial Rejection E]Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ra+- Faciliys Phone: <br /> W 1B.Signature ofNtemate Faciliry(or Generator) Month Day Year <br /> r <br /> a <br /> z <br /> N19.Hazardous Waste Report Management Method Codes d,e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. T <br /> 4. <br /> A631 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> jiwillitIfyiped NameSignatu Month Day Year <br /> M 06 )-(, <br /> EPtA ch 4Wil�t&6 Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STAT (IF REQUIRED) <br />