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SSL SK SHIP# 223737802 rkr IIIIIIIIIII'III�I�IIII'IIIIIIIIIIIIII <br /> 0061932165 KS <br /> Please print or type.(Form designed forum on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Pa 1 of E cY n P 4.Manifest Tracking Number <br /> WASTE MANIFEST TXR0000B1205 '���- 1006193216 SKS <br /> 5.Generator's 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 /> s.gi YJrVEFyeSYSTEMS INC U.S.EPA ID Number TXROOOOD1205 <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 10 Number <br /> 6880 SMITH AVE. <br /> NEWARK , CA 94560 <br /> 510-795-4400 CAD980B87418 <br /> Facililys Phone: <br /> gra 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containam 11.Total 12.Unit 13 Waste Cedes <br /> HM and Packing Group(if any)) No. Type Quantity WIN& <br /> ' NON—RCRA HAZARDOUS WASTE, LIQUID TT 6 221 <br /> o (USED OIL) <br /> 3 ZZ <br /> 2 2. <br /> w <br /> (9 <br /> 3. <br /> 4, <br /> 14,Special Handling Instructions and Additional Information TSD:EVG SAL CSG: 1 <br /> 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) <br /> AUTH 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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulators.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)if I am a large quantity generator)or(b) ' am Ismall quantity generator)is true. <br /> Generat Offerors Pnntedrfyped Name Signature Month Day Year <br /> rJ <br /> 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Pon of entry/ext: <br /> z Transporter signature(for exports only): fl Date leaving U.S.: <br /> w 17.Tmn=Acknowledgment of Receipt of Materials - <br /> Tans r 1 Pnnted/fyped Names Signature Month Day Year <br /> a ke:d ( O 301(7 <br /> Qporter2 Printed/Typed Name Signature Month Day Year <br /> C <br /> H <br /> I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity ❑Type El Residue Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 186.Alternate Facility for Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> 18c.Signature of Alternate Fackity(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> G i. 2. 3. 4. <br /> Ho3� <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item las <br /> Printedfryped Nam- ` Signature Month Day Year <br /> T 1 . , �UVu Wv D 00 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESYNWDFACILITYTODESTINATIONSTATE(IFREQUIRED) <br /> 1) 11249/156017 <br />