Laserfiche WebLink
SSL SK SHIP# 220683401 IIIIIIIIIIIIIIIIIIIIIIIIIIINIIIIIII <br /> 0057280668 K3 <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.Pag 1 of 3.E % ppm 4.ManifestTmcking Number <br /> WASTE MANIFEST TXR@@@@812@5 el 1 -41 76@ 005728066 SKS <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 CR 95368 <br /> Generators Phone: 209-545-1011 SALIDA CA 95368 <br /> 6.Tp0sgoa.,+9 <br /> repanv.Name SYSTEMS INC. U.S.EPA ID Number <br /> , TXR@@0@81205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> as b <br /> 8.Designated Facility Name and Site Address THERMO FLUIDS INC U.S.EPA ID Number <br /> 4301 W JEFFERSON ST <br /> RHOENIX , AZ 85043 <br /> RZR000003681 <br /> 8@0-350-7565 <br /> Facililys Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13'Neste Codes <br /> HM and Packing Group if any)) No Type Quantity WLNd <br /> 1 NON-RCRA HAZARDOUS WASTE SOLID z DM 25C P 223 <br /> o (DRAINED/UNDRAINED USED bIL FILTERS) <br /> qa <br /> z z. <br /> W <br /> c9 <br /> 3. <br /> i <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:TPA SAL CSG:(,�� <br /> 24 HR EMERGENCY #1-800-468-1760 (SK ! TFI) b ( � 61 b 11 q� <br /> RUTH AS "AGENT-FOR" BY GEN TO RETAIN LI (SIRS" IRY <br /> 15. GENERATOR'SIOFFEROR'S CERfIRCATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassfied,packaged, <br /> marked and Iabelec/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.f 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 Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generators/Offeror Printed/typed Name Sig Month Day Year <br /> Mot <br /> �j 16.International Shipments <br /> r <br /> El Import to U.S. LJ Export from U.S. Pon of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.TranspmerAdmoMedgment of Receipt of Materials <br /> Transporter 1 Printedlryped Name Sig Month Day Year <br /> Irensporler 2 PrintedRyped Name Sign re � M Day r <br /> - , <br /> 18.Discrepancy <br /> lteiewt 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. r <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Facility's Phone: <br /> Mia 18c.Signature of Alternate Facility for Generator) Month Day Year <br /> G <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of haze ous materials covered by the manifest exceptin Item 18a <br /> PrintedRyped Name � Signature / M V <br /> G� ea <br /> `/ O 1 <br /> EPAForn 8700-22 Rev.3-0 Previo editions are obsolete. DESIGN D FACILITY TO DESTINATION STATE (IF REQUIRED) <br /> 1)7872676/156 33 <br />