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SSL SK SHIP# 22266483611111111 11111 <br /> 0 0 6 1 0 0 5 5 4 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 CAT000613968 12.1 1 of 3.ErysrpppcyR•sppnse Pbone. 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 <br /> �� 1 G�7Y7 400 1 ybl7 006100554 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Safety-Kleen Systeles, Inc. <br /> 5050 Salida Boulevard <br /> SALIDA CA 95368 <br /> Generators Phone: 209-545-1011 <br /> 6. V-n' oeSYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.Transporter Company Name U.S.EPA ID Number --y� <br /> �v <br /> 8.Designated Facility Name and Site Address THER 0 FLUIDS INC U.S.EPA ID Number <br /> 12533 SE CARPENTER DR <br /> CLACKAMAS OR 97015-8988 <br /> 503-788-4616 01490100825197Facll' s Phone: <br /> gy 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 Gmup(if any)) No. Type Quantity WtNol. <br /> 1NON-RCRA HAZARDOUS WASTE SOLID DM P 223 <br /> o (DRAINED/UNDRAINED USED OIL FILTERS) ;-)s <br /> z 2. <br /> wit <br /> U <br /> 3 <br /> 4, <br /> 14.Special Handling Instructions and Additional Information TSD a TPO SSL CSG: <br /> 24 HR EMERGENCY #1-800-468-1760 (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 Iabeledlplacarded,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,l certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmem of Consent. <br /> I cedify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) rf small quantity generator)is We. <br /> ratarsrOffem(s Printed(Typed ame Signa Month Day Year <br /> c\1 �1 C, 17 <br /> —.1 16.International Shipments rt .S. /exiC <br /> F L1 Import to U.S. ❑Expo Port ofe ntry <br /> Transporter signature(for exports wiry): <br /> Date leaving U.S.: <br /> W 17.Transpo tar Acknowledgment of Receipt of Materials <br /> Tra r i Printed/Typed Na ry9 Signa Monty iay Year <br /> y <br /> Transporter Pd Name afore Month Day Year <br /> 1-7r <br /> G✓hJ{�'\ <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partlal Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 181b.,Aftemate Fadltty(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facilitys Phone' <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 1 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PnntedlTyped Name Signature Month Day Year <br /> Y— 1 <br /> E1)7872676PA Form 8700-22 editionsareobsolete. DESI A E FACILITY TO DESTINATION STATE(IF REQUIRED) <br />