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SSL SK SHIP# 223664762 IIIIIIIIIII'IIII'IIIIIIIII'I'IIIIIII) Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 0 0 6 Form Approved. MB N5 2050-0039 UNIFORM HAZARDOUS 1,Generator ID Number TXR000081205 2 Pa 1 of 1 4.Manifest Tracking Number WASTE MANIFEST 006192442 SKS 5,Generators Name and Mailing Address Generamrs Site Adtlress(if difiemnl than mailin address) SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN SYSTEMS, INC. PO BOX 555 5050 SALIDA BLVD SALIDA CA 95368 Generators Phone: 209-545-1011 SALIDA CA 95368 6gffft t&"SYSTEMS INC U.S.EPA ID Number TXROMOS1205 7.Transporter 2 Company Name U.S.EPA ID Number CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 8.Designated Facility Name and SiteAddress THERMO FLUIDS INC U.S.EPA ID Number 12533 SE CARPENTER DR CLACKAMAS , OR 97015-8988 000 503-788-4616 ORD025197 Facilitys Phone: Sal 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity WCNoI. ' NON—RCRA HAZARDOUS WASTE SOLID DM P 223 o (DRAINED/UNDRAINED USED bIL FILTERS) 1 Sbd W z z. W f7 3. 4. i 14.Special Handling Instructions and Additional Information TSD:TPO SAL CSG: t-76 52a,,FOU-7 1 -7655 71 / 76E�T2-,7&/ 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) AUTH AS "AGENT—FOR" BY GEN TO RETAIN LICENSED SUB CRRRIERS RS NECESSARY 15. GENERATOR'S/OFFEROR'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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(iii a mall quantity generator)is true. GeratoeslOffer rs Printed/fy�Name Sign Month Day Year U J 16.International Shipments i ❑Import to U.5. ❑Expo .5. Port of entry/exit: Transporter signature(for exports only)'. Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Tr porter 'nted/Typed/\pj��'me Signal Month Day Year Q Transporter 2 Printe Name ignaWre Month Day Year ersD1 1101 1:7 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Ntemate Facility(or Generator) U.S.EPA ID Number J C) LL Facilityss Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2, 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a jll Pnnted/Typed Name Signature Month Day Year J � �� EP)7872676%3560 Previous ditionsare obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)