Laserfiche WebLink
SSL SK SHIP# 222417890 111111111111111111111111111111111111111 <br /> 0 0 6 0 9 9 7 5 9 S K 3 <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 TXR000081205 2.Pagyi of 3.lEmaf9@pgy ReSpgOse Phone® 4.Manifest Trackin Number SKS WASTE MANIFEST tt tltlr�111rrDD 4btl 1/b 0 0 60 9759 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailingaddress) <br /> SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN SYSTMS , INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CR 95368 <br /> Generators Phone: 209-545-1011 SRLIDR CA 95368 <br /> U.S.EPA ID Number TXR000081t-05 <br /> 6.T� F�A���YeSYSTEMS INC ' <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 , CR 94560 <br /> CRD980887418 <br /> 510-795-4400 <br /> Facili 's Phone' <br /> go. go.U.S.DOT Description(inducing Proper Shipping Name,trained Class,ID Number, 10.Containers 11.Total 12.Unit <br /> and Packing Grow if an Quantity Wtivol. 13.Waste Cotes <br /> HM 9 P( YII No. Type ty <br /> 1 NON—RCRA HAZARDOUS WASTE, LIQUID TT G 221 <br /> o (USED OIL) <br /> on ► S'LS <br /> z 2. <br /> w <br /> CD <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additionat Information TSD:EVG SAL CSG: I <br /> 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) <br /> RUTH AS. "ASENT—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 aoouretely described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacanded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment canfonn to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement idenfified in 40 CFR 262.27(a)it I am a large quantity generator)or(b)(g I am a smal(quarridtfoanaijItton is true. <br /> Generator rots Printed7Typed Name Signature Month Day Year <br /> lo7l IL117 <br /> .J 16.—International Shipments <br /> F- ❑Import to U.S. ❑Export from U.S. Port of entry <br /> Transporter signature(for exports only): Date le 'ng U.S.: <br /> 19 W 17.Transporter nomedgment of Receipt of Materials <br /> Transporter i ntedlTyped Name Signature Month Day Year <br /> N (�� 07 / I <br /> Q Transporter Prinmdrlyped Name Signature Month Day ear <br /> K <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Ouamtyy <br /> ❑Type El Residue ElPartial Rejection ElFull Rejection <br /> Manifest Reference Number. <br /> tab.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> I Facility's Phone: <br /> MM, mc.Signature ofAkemate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> LD <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> G i. 4;,f 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manfiest except as noted in Item like <br /> Prntedrryped Name Signature Month Day Year <br /> p-ppT�ygi-qw• � i i <br /> EPAT��'�49/156.01� Previous editions are obsolete. IGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />