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f3L SK SHIP# 2EO2985O8 IIIIIII IIIA5 259 5IIII IIII III <br /> Please print or .(Foml desig ad for use on elite(12-gkh)ryp mar.) Fan Appi OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.GerarebrlD Npmher 2.Papela 3Emagamar Rapanw Pana arms <br /> c �ZN3959 SKS <br /> WASTE MANIFEST TXROOOO812O5 1 1-800-468-1750 n <br /> 5.Gararelae NameaM MNI'mg Fddress Gemrelofs SimAddmu lifdifferent than matling adrenal <br /> SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN SYSI,-hi INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CR 95368 <br /> Genereta's Pibro: <br /> S.Train 1 Coal Name U.S.EPA ID Narrater <br /> SAFETY—KLEEN SYSTEMS, INC. TXR0000B1E'O5 <br /> 7.Thaws l2 fnnaany Name U.S.E A <br /> &Casgnaletl FxNiry NartaeM SAeAtldrem <br /> US EPA ID Numbs <br /> SAFETY—KLEEN SYSTEMS, INC. <br /> 6000 BOTH STREET <br /> SACRAMENTO , CR 95828 <br /> F sPmne.. 916-385-4913 CAOOOOO84517 <br /> HMS US.DOTD PW(emMNg Pmpa Shppbg Name,) CW%IDNum ,, " j lo.loanumman 11.Trial 1z.Und ,O.WaeaCgdee <br /> aro Pa NnBGiuuP lAenrl) 'S'/' No. T, oaram, WINd. <br /> o - <br /> W Z <br /> o NON—RCRR <br /> HAZARDOUS WASTE LIQUID _, DM- G 134 <br /> (R0UE0US PARTS WASHER SOLUTION) <br /> 3. <br /> 4. <br /> 14.SpedN Han®bp lrobuctiplsaMAdtlipmYlMamalion <br /> T5D:SCA --1 SAL CSS: <br /> 24 HR Ef '+ --F,00 - 1760 !SK ! TFI) 1 ' � <br /> 1 . 'SI)FFEROR'SCERIIFICATON'. l hereby declare rel ing reme.aMaredaseifad,pecapeq <br /> maned and bbeledrpamrdeb,and are In all reapeck In proper mndbbn mrtranslsnrtauwtlirgbepplimbkitlemeEpnelaq mall garsmne^,N regWaAme.Nei shipmea laM I am the PAmary <br /> Fxpa,er,I ceNty bat Ne mmm�k moria cpnvgnment cpnbrm mUa taresdNealmaaa EPAAdnaMetlgmenla Cpuant <br /> Im1➢M1J WIuce wasm minimied0dn statement idenliFmtl in40 CFR 26227(a)(dl emakrpe guanurygerreremrl mlbl lelameana6wanMrwmremrlk Wo. <br /> IMNOrtxors minteMylaed NameNomil Day Year <br /> M mol <br /> ay t� <br /> F , .inMmetaral5ngmank <br /> ❑ImpodmUS. ❑Expm"US. Paldenti xN <br /> i Trenspalersgramre(mraxpmk only): Dabkmhg US.: <br /> 17.Thermal PickinaNdelgarent m Redipl of MIDeas N 0" Y. <br /> O apmtml G�raM Name e� Sgnal Monty a4 I. <br /> y 1" it 94 <br /> ral Name S' arms MmN DaY Yeer <br /> �G€ !/J <br /> 1 1e.Dkmean" <br /> 119a.Drerapenglnadmidon Spam ❑ Ousntity ❑Type ❑Residue El Roddy. ❑FUIIReIedal <br /> Manibst Refers.Number: <br /> ISb,NMmINe Fa iity lorGernramr) US.EPAID Nurrtl <br /> U <br /> u FatllAya Plwra' <br /> W ,en SmalldfNkmate Far lmGerareW) Monty Day Y. <br /> 1� <br /> y1g.HaaeNms Waeb RepMManagemeMMeNotl Catlin li.e.,mdasb FaaaiCmovresle treaanaM,dkpcaal.eMrecyamg eysbno) <br /> 1. <br /> X1481 - H141 .NF1r� <br /> 2o.0e9gnshd Faciiy Mrara Ope2mr:CaMNationaresplalhamNws maMrnakmrered Dy Ne manAeslaxcept as rNetl N Xem 1Ba p5 <br /> 1 S 1 ✓ 2, rer <br /> EPAForm 700-22(Re ) PrMous ( <br /> edinom are o0wkle. p IGNAT DFACILITYTODES ATION STATE(IF REQUIRED) <br /> 1) 14626/156013 2) 14941/t56O23 .3) 14941/156025 <br />