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����" Illilllllillllillllllllllllllllllllll <br /> SSL SK SHIP# 223737854 0 0 6 1 9 3 2 7 3 3 K 5 <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.Paye 1 of 3.Emergency Response Phone 4.Man'dest Trackin Number <br /> WASTE MANIFEST TXR000081205 1 1-800-468-1760 100 <br /> 6193273 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN <br /> BSYSTEMS, INC. <br /> PO BOX 555 CA 95368 <br /> LVD <br /> SALIDA <br /> Ge Transporter <br /> 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 CAD980887418 <br /> Facility's Phone: 51®-795-4400 <br /> 9a 91b.U.S.DOT Description(including Pmper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(it any)) Na. Type Quantity Wt.No1. <br /> 1.NONRCRA HAZARDOUS WASTE,LIQUID TT 6 133 <br /> a <br /> ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) �O <br /> w <br /> z 2. <br /> w <br /> co <br /> 3. <br /> a <br /> 14.Special Handling instructions and Additional Information TSD:EVG SAL CSG: <br /> 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) <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 Iaoeled/placaNed,and are in all respects in proper condition for transport according fo applicable international and national govemmental regulations.If export shipment and I am the Pnmary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknoW edgment of Cgifaint. ' <br /> I certify that the waste mmim¢abon statement identified in 40 CFR 262.27(a)(If I am a large quantity generator)or(b/flarngliftimiall quantity generator)is We. <br /> Generaforsl ots Printed/Typed Name Signature Month Day Year <br /> J 16.International ShipmentsEl <br /> F ❑Import to U.S. Export(ram U.S. 17 Port ofentry/ezR: <br /> = Transporter signature(for exports only): Date leaving .5.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter PrintedRyped are Signature Monts Day Year <br /> a ( 1Ito 17jo 1 /7 <br /> QTransporter 2 PrintedlTyped Name Signature 17 Month Day Year <br /> K <br /> r <br /> 18.Discrepancy <br /> t 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 181b.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 Day Year <br /> 6 <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. I 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certificabon'of receipt of hazardous materials covered by the manifest except as noted in Rem 1 <br /> Printed"yped Na SignatureMonth Day Year <br /> �i r Zutit /0 30117 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DE ED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 1)651/156030 <br />