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SSI. SK SHIP# 2219.322325 �/�f f/ IIIIIIIIIIIIIIII��IIIIIIIIIIIIIIIIIII <br /> 0059471693 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 ('AT000513968 2.Pn M 3.Emer9erlFy Raspppga pbona0 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 1 t'101Cr 468 1 /b 005947169 SKS <br /> 5.Generators Name and Mailing Address Generakies 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 CA 95368 <br /> Generators Phone: 209-545-1011 SALIDA CA 95368 <br /> 6.Tpfgyr?"it�7yi9apte SYSTEMS INC U.S.EPA ID Number TYROOOOS1205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and She Address SAF ETY-KLEEN OF CALIFORNIA U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK , CA 94560 <br /> CAD980887418 <br /> 510-795-4400 i <br /> Facility's Phone: <br /> go. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12 Unit 13 Waste Codes <br /> HM and Packing Group IN any)) <br /> No. Type Quantity Wt.Nol. <br /> 1. NON RCRA HAZARDOUS WASTE,LIQUID TT G 133 <br /> o ETHYLENE GLYCOL SOLUTION (LESS THAN 50%r <br /> oc> i 2.10 <br /> M 2. <br /> W <br /> t7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional information TSD:`:. SRL CSC. ' <br /> 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) <br /> ITH AS "AGENT-FOR" BY GEN TO RETAIN LICENSED -Q . AS NECESSARY <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby tledare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations.If export shipment and I am the Pnmary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 1 certify that the waste minimaotion statement identified in 40 CFR 262.27(a)If I am a large quantity generator)or(b)(if I am a loall ajanfity generator)is true. <br /> Generator Offerors PrintedlT Warne Signature Month /Day Year <br /> 17 7 <br /> 16. a oral Shipments <br /> _ ❑Import to U.S. ❑Export from U.S. P f antrylexit: <br /> Transporter signature(for exports only): leavi U.S' <br /> a' 17.TransporterAcknowledgment of Recaiptof Materials <br /> O Transporter rintedm <br /> lryped Nae Signature ` Month Day Year <br /> QTra a Pnn ed/Typed a Signature Month /Day Year <br /> is.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity ❑T Residue <br /> Type El ❑Partial Rejection F1 Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility lar Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone. <br /> H18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> m19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. iY( 2. 3. 4. <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 B <br /> Printedlryped NameN� z� signature Mo th Day Year <br /> opl EPl F &05) Previous editions 7lamobsooletee.._ <br /> omk87Q0-2 &( DESIGNATED FACfITYTO DESTINATION STATE(IF RE UIR ) <br />