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SS!_ SK SHTP# 221932330 ( �l/ I�IIIIIIIIIIIIIIIIIIII�IIIIIIIII <br /> 0059471745 KS <br /> Please print or type.(Form designed forum on elite(12-pitch)typewnter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generalor lD Number CAT000613968 2.Pagell of 3.Em Rpttr RhMo 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 L 005947174 SKS <br /> 5.Gerwalots Name and Mailin Address Generators SiteAddrass H m tlran Ji address) <br /> SAFETY—FLEEPP SYSTEMS, INC. SAFETY—K EEN SY"ST MS, INC. <br /> PO BOJ( 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> GeneratarsPhone: 209-545-1011 SALIDA CR 95368 <br /> 6.T r r.)i.Comonn SYSTEMS INC U.S.EPA ID Number TXROOOOB1205 <br /> 7.Transporter 21C'oomppanny Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK , CR 94560 <br /> CAD980887418 <br /> 510-795-4400 <br /> Facililys Phone: <br /> Pa. go.U.S.DOT Description(including Pmper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM <br /> and Packing Group(if any)) No. Type Quantity wt/vol. 13.Waste Codes <br /> NON RCRA HAZARDOUS WASTE,LIQUID TT G. 133 <br /> o ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) <br /> z 2 <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:EVG - 1 <br /> 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) <br /> RUTH AS "AGENT—FOR" BY GEN TO RETAIN LICENSED SUB CARRIEP.S AS NFCEO-SRRY <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shippng name,and are dassified,packaged, <br /> marked and labeledlplacerded,and are in atl respects in proper condition for transport according to applicable international and national govemmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to bre tens of the attached EPA Acknowledgment of Can nt. <br /> I certify that the waste minimization statement identieed in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)( m aArnall quantity generator)is true. <br /> Genera rsrOflemes Pnnted(fyped.Name Signature ` Month Day Year <br /> 16. n7fligonal Shipments <br /> F ❑Import N U.S. ❑Export from U.S. Port ofentry/exd: <br /> = Transporter signature(for exports only): Dat leavirg U.S.: <br />' W 17.TransporterAcknmvledgmem of Receipt of Materials <br /> Trans r 7 PnntetlRypetl Name Signature Month Day Year <br /> a �i ) <br /> CO) <br /> Qransporter 2 Pnnted?ypetl NameSigna"s MonthDay Year <br /> C <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El 1:1 <br /> Quantity Type ❑Resitlue ❑Pamal Rejection ❑Full Rejectlwr <br /> Manifest Reference Number: <br /> 181b.Altemate Facility for Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � 1. � 2. 3. 4. <br /> 20.Designated F cility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item laa <br /> PnntedFFyped Nam Signature Month Day Year <br /> to <br /> EP1 F011 y9p,2jj(R y19-05) Previous ons are obsolete. DESIGNATED WLITYTO DESTINATION STATE (IF REQUIRED) <br />