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SSL SK SHIP# 220676387 C?w IIIIIIIIIIIN111p11p11p11111111111 0057267811 K3 Please print or type.(Form designed forum on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number CAT000613968 2.Page11 of 3.Emq�gOgy Respgpse Ptgga0 d.Manifest Tracking Number WASTE MANIFEST 1 tlfOrO 4r IW" I /b 006,15728781 0 C J 2 Q 7 Q 1 S V S 5.Generators Name and Mailing Address Generators Site Address(it different than mailing address)/ O O J nJ SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN SYSTEMS, INC. PO BOX 555 5050 SALIDA BLVD SALIDA CA 95368 Generators Phone: 209-545-1011 SALIDA CA 95368 6'T9ffPM'—nRSYSTEMS, INC. U.S.EPA ID Number TXR000081' - 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA, INC. U.S.EPA ID Number 6880 SMITH AVE. NEWARK , CA 94560 510-795-4400 CAD980887410 Fal Phone: ga Sb.U.S.DOT Desorption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group if any)) No. Type Coal Wt.Nol, 1. NON RCRA HAZARDOUS WASTE,LIQUID TT 6 133 o ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) //—� �O 1 FfN Z 2. w f7 3. 4 14,Special Handling Instructions and Additional Information TSD:EVG SAL CSG: ' 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) RUTH AS "AGENT—FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY 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, marked and Iabeletllplacerded,and are in all respects in proper condition for transport according to applimble international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(g I am a large quantity generator)or(b)(if I am a s II q nfity generator)is true. GeneraWrsl rocs PdntetllTyped Name Signature Month Day Year b>~s OL a 16.International Shipments Import to U.S. z ❑ ❑Expod from U.S. P entrylexit: Transporter signature(for exports only): 0 ving S.: Lau 17.Transporter Acknowledgment of Receipt of Materials Transp er 1 Printedrryped Name Signature Month Day Year i 6Z DZ 7 GTransporter 2 PrintediTyped Name Signature Month Day Year K 18.Discrepancy 18a,Discrepancy Indication Space Quantity Type ❑Residue ❑Partial Rejection ❑Fill Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: W 1ac.Signature of Alternate Facility(or Generator) Month Day Year Q 2 y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Lau , 1 1 I 2. I 4. I` 20.Designated Facility Owner or 'ficebon of receipt of h rdous materials covered by the manifest except as acted in It 18a Prime.d(Tyoed Name Signature Month Day Year a2 ut EPt5fa.8700:�lR &05) Previou d' Bare obsole . DESIGN AGILITY TO DESTINATION STATE(IF REOUIRED)