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SSL SK SHIP# 221932336 11111111111111111111111111111111111111 <br /> 0059471803 K3 <br /> Please print or type.(Form designed forum on elite(12-pitch)typewriter.) E pomace gho� Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAT 000613968 2.Page11 of 3'!m _RX- f5-1 /tt0 4.Manifest Tracking Number <br /> WASTE MANIFEST 1005947180 SKS <br /> Genera ddi8erent than ilin address) <br /> 6.Glo�s�({�meL1 ATEMS, INC. iFTVEEtd SYST�MS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209-545-1011 SALIDA CA 95368 <br /> 6.Trer)er)1np SYSTEMS INC U.S.EPA ID Number TXR000081206 <br /> 7.Transporter 2 Company 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 , CA 94560 CAD98088741P <br /> 510-795-4400 <br /> Facllity's Phone: <br /> 9, 9b.U.S.DOT Description(including Proper Shipping Name,Hi Class,ID Number, 10.Containers11.70tal 12.Unit13.Waste Codes <br /> HM and Packing Group(8 any)) No. Type Quantity WtNol. <br /> 1. NON RCRA HAZARDOUS WASTE,LIQUID TT G 1?7 <br /> o ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) - <br /> 00 1170 <br /> z 2. <br /> W <br /> CO <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:EVG SAL I 1 <br /> 24 HR EMERGENCY #1-8.00-468-1760 (SK ! TFI) <br /> RUTH AS "AGENT-FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <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 labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.R export shipment and I am the Primary <br /> Exporter,I certify,that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Corpnt. <br /> I terrify that the waste minimization statement identified in 40 CFR 262.27(a)If I am a large quantity generator)or(b)(8 m a all quantity generi is true. <br /> Generetat rots Pdmed/Typ(yl Name Signature Month Day Year <br /> ®{p eT- <br /> j 16.International ShipmentsEl <br /> p_ ❑Import to U.S. Export from U.S. Port of entry/exit: <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter AduvMedgment of Receipt of Materials <br /> Transporter Printed/Typed Name Signature ! Month Day Year <br /> a <br /> 'i @'f 117 <br /> QTransporter 2 PnntedfFyped Name Signature Month Day Year <br /> K <br /> f- <br /> ♦ 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type El ❑P.mal Rejection ton Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facilitys Phone. <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 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 1a <br /> Printed/Typed Namel Signature Month Day Year <br /> )OV <br /> hnAZc 14 <br /> EPtFMy5p-�? W5) Previous editions are olowlete. (/�r/s,�� DESIGNATED If ILITYTODESTINATION STATE(IF REQUIRFD) <br />