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SSL SK SHIP# 220743630 /,� I�IIIIIII�I�IIII�IIIII��II'I�IIIII"II <br /> OG9T2bibb8Kto <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.20W-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Er�e�e R nse P e 4.Manifest T`� Number <br /> WASTE MANIFEST TXRO@0081205 1 1'fd1(1`&-4T8-176@ 005728186 SKS <br /> 5.Generaws Name and Mailing Address Generators Site Address(a di8erers 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.Tran�Fiter 1 Compan Name U.S.EPA ID Number <br /> SETY—KL�EN SYSTEMS, INC. TXR@00081205 <br /> 7.Transporter 2 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 /> 688@ SMITH AVE. <br /> NEWARK , CA 94560 CAD980887418 <br /> 51@-795-44@0 <br /> Fadlilys Phone: <br /> ga 9b.U.S.DOT Desorption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(Aany)) No. Type Quantity Wt./Vol. <br /> 1' NON—RCRA HAZARDOUS WASTE, LIQUID TT G 221 <br /> of (USED OIL) <br /> z z <br /> W <br /> l7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:EVG SAL CSG: I <br /> 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) <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,and are classified,packaged, <br /> marked and IaOekNplamrded,and are in all respects in proper condition for transport according to applicable intema6onal din ab al 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 a8ached EPAAdmowledgment of Co ni <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(8I am a large quantity generator)or(b)(If m a all quantity generator)is We. <br /> Generetorsl rats Printed/Gved Name Signature Monts Davy Year <br /> Z L 1for <br /> 16.Intemdional Shipments <br /> F ❑Import tc U.S. ❑Export from U.S. ort of ent ylexit: <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TwspxterAdmoWedgmentof ReceiptufMatedals <br /> Transporter 1 rinled7ryped Name Signature Month Day Year <br /> ait It I Zl 1 16 <br /> GTran 2 Prifileciffyped Name Signature Month Day Year <br /> K <br /> t— <br /> ♦ 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejectbn <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> L) <br /> ri Facility's Phone: <br /> W 18c.Signature of Ahemate Facility(or Generator) Month Day Year <br /> Q <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1 r 2. 3. 4. <br /> 20.Designated Fa'Iity Owner or Operator.Certification of receipt of hamrdous materials covered by the manifest except as noted in Item 18a <br /> Pdntedrryped Name Jo n _ Signature -Month Day YearDUv;c-- It, <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGN T D rACILITYTO DESTINATION STATE(IF REQUIRED) <br /> 1)11249/156017 <br />