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SSL SK SHIP# 222069165 6311r II�IIIIIII�IIIII'I�IIIIIIIIIIIIIIIIII 0059465593 K3 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMR No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number TXR0000812@5 2.Page 1 of 3.lEmgs 9(.y Ite�pgpse P9ryg_ 4.Manifest Tracking Number WASTE MANIFEST G 1100 4bC 1,bf0 005946589 SKS 5.Generators Name and Mailing Address Generetors Site Address(if different Man mailing address) SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN SYSTEMS, INC. PO BOX 555 5050 SALIDA BLVD SALIDA CA 95368 Generator's Phone: 209-545-1011 SALIDA CA 95368 1.Tgo ETY mI�L EN SYSTEMS INC U.S.EPA ID Number TXR000081205 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA U.S.EPA ID Number 6880 SMITH AVE. NEWARK , CA 94560 CAD980887418 510-795-440@ Facility's Phone: 9a 9b.U.S.DOT Description(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 Quantity WI.No1. ix NON RCRA HAZARDOUS WASTE,LIQUID TT G 133 o ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) Zy0 G c7\ 7 z 2. W 0 3. 4. 14.Special Handling instructions and Additional Information TSD:EVG SAL CSG: I 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) RUTH AS "AGENT—FOR" BY GEN TO RETAIN NS SUB CARRIERSAS 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 labeled/placarded,and are in all respects in proper cond8ion for transport according to applicable international and natio I governmental regulators.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the teems of the attached EPA Acknowledgment of Con I certity that the waste minimization statement identified in 40 CFR 262.27(a)i I am a large quantity generator)or(b)(if I a a II quantity generator)is true. Generators) rots Pnnted(Typ d Name„ Signature Month Day Year 07 Z 16. rnationa hipments 1:1 Import to U.S ❑Export from U.S. Port of entrylexiC !- . Transporter signature(for exports only), Date leavig U.S.: f w17.Transporter Acknowledgment of Receipt of Materials � Transporter Pnnled/ryped Nam ` Signature 2 Month Day Year/Yea�)r N Q sporter 2 Printed yped Name Signature Month Day Year K r— 18.Discrepancy, 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Full Re Ll ❑Partial Rejection lection Manifest Reference Number: 11 Alternate Facility(or Generator) U.S.EPA ID Number J V rai Faalipys Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G i. 2. 3. 4, 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as ntled in Item 19a till Pnntedrryped Name e Signature Month Day Year 7 1 23 11 EPA Fo8700-g ey,i Previo edition are obsol . DESIGNATED F ILITYT STIN TION STATE(IF REQUIRED)