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SSL SK SHIP# 223200788 8'3©99 1111111111111111111111111111111111111111 <br /> 0 0 6 1 3 6 2 9 5 S K S <br /> Please print or type.(Form designed forum on elite(12-pitch)typewriter.) Form Approved.OMB No.205MG39 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST I TXR000081205 1 1-800-468-1760 1006136295 SKS <br /> 5.Generators Name and Mailing Address Generators 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.Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY—KLEEN SYSTEMS INC TXR000081205 <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 <br /> FadlBys Phone: 510-795-4400 CAD980887418 <br /> ga 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 litany)) No. Type Quantity Wt.Nol. <br /> Ix NON—RCRA HAZARDOUS WASTE, LIQUID TT G 221 <br /> (USED OIL) G,::> <br /> ( <br /> z Z <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:EVG SAL CSG: <br /> 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) <br /> Air u <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.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment confoml to the terms of the attached EPA Acknowledgment of Consent. I <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a All q Sty generator)is We. <br /> Generators/ rots PrintedlTypedJ>I�me Signature Month Day Year <br /> /L 1671/ 7 <br /> 16.InterriBidTfifirShipments <br /> i ❑Import to U.B. El Export from U.S. entry/ <br /> Transporter signature(for exports only): //.is leaving <br /> ex' <br /> w 17.TransporterAcknowledg t of Receipt of Materials <br /> Transporter)PdntedR ame Signature Month Day Year <br /> 0ILa7l7 <br /> QTransporter 2 Prifffecirlyped Name Signature Month Day Year <br /> K <br /> H <br /> I <br /> 18.Discrepancy <br /> fila.Discrepancy Indication Space ElQuan' <br /> Quantity ❑Type El Residue ❑Partial Rejection ❑full Rejection <br /> Manifest Reference Number: <br /> 1B6.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> Maj 18C.Signature of Alternate Facility(or Generator) Month Cay Fear <br /> z <br /> H19.Hazardous Waste Report Management Metlwd Codes(i.e.,codes far hazardous waste treatment,disposal,and recycling systems) <br /> � 1 2. 3, 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of haaardous materials covered by the manifest except as ni in Item 18a <br /> PrintedlTypetlA ore Signature Month Day Year <br /> G <br /> EPA Form 8700-22(Rev.3-05) Previou Itionsareobs e. DE IG ED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 1) 11249/156017 <br />