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SSL SK SHIP# 219566252 0 0 5 5 2 2 6 1 9 8 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.ManHast Tacking Number �� <br /> WASTE MANIFEST TXR@00081205 1 1-800-468-1760 <br /> 5.Generators Name and Mailing Address Generators Site Address if different than mailing 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.Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY—KLEEN SYSTEMS, INC. TXR@@0081205 <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, INC. US.EPA ID Number <br /> 6000 88TH STREET <br /> SACRAMENTO , CA 95828 <br /> Fadlity's Phone: <br /> 916-386-4913 CR0000084517 <br /> 9a 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 M.Nol. <br /> BF <br /> Oa � <br /> K <br /> 2. NON—RCRA HAZARDOUS WASTE LIQUID DM ' oo G 134 <br /> (AQUEOUS PARTS WASHER SOLUTION) <br /> 3. <br /> 4. ry <br /> 14.Special Handling Instructions and Additional Information TSD:SCA <br /> 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) 22 ;/( . 13u0 D q),CVCt o J <br /> AUTW PC: <br /> n _ n e <br /> 16. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby dedare that the contents of this consignment cora Ily antl accurate y tlescribetl a ve y e proper s tipping name,and are dessified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemati rid 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 Acknowledgmen nsent. <br /> I certify that the waste minimization statement idenfified in 40 CFR 262.27(a)(if I am a large quantity gene (if I am a small quantity generator)is true. <br /> G torslOfferor rtntetlRypame Monty Year <br /> �Chd� �Gv ly 1TQ <br /> 16.International Shipments <br /> F ❑Import to U.S. El E.MKm U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w17.Transporter Acknowledgment of Receipt of Materials <br /> r' der 1 Pd dtRy�ped N Signa Month Day Year <br /> IL <br /> Transporter PrintedlTyped Name Slhature Month Day Year <br /> K <br /> I <br /> 18.Discrepancy <br /> fila.Discrepancy Indication Space Ll 11Type ElResidue ❑PaNal Rejaction ❑Full Rejection <br /> Manifest Reference Number <br /> 181,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facililys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> h19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and meyding systems) <br /> 0 1. z. H141 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> JJJJJJ Printed? Name nature / f Month Day Year <br /> Sig <br /> EPA Form 8700-22 Rev.M5 Previous editions are obsolete. DESIGNATED FACILITYTO DESTINATION STATE(IF RE01,1IRED) <br /> 2) 14941/156023 1"494tfi�6023 <br /> I ,,��tt <br />