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SSL SK SHIP# 223737858 � IIIbIIIIIIIIiHflIIUINim�llll <br /> 006193216SKS <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 2.Ill of 3.Emer envy Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST TXROOOOB1205 1 1-8�0-468-1760 1006193288 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address in 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 /> Gecerators Phone: 209-545-1011 SALIDA CA 95368 <br /> 6.Tran Mar 1 Company Name U.S.EPA ID Number <br /> SA ETY—KLEEN SYSTEMS INC TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and She Address SAFETY—KLEEN OF CALIFORNIA U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK , CA 94560 <br /> 510-795-4400 CAD9B0887418 <br /> Facili s Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,0 Number, 1o.Containers 11.Total 12.Unit 13 Waste Codes <br /> HM and Packing Group(9 any)) No. Type Quantity M.Ml. <br /> z ''NON RCRA HAZARDOUS WASTE,LIQUID TT G 133 <br /> R ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) �O I <br /> z 2. <br /> w <br /> t9 <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 /> _ rr <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are Polly 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 international an nation governmental regulations.H export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment coMomi to the terms of the attached EPA Acknowledgment of Conse . <br /> I cerfdy that the waste minimization statement identified in 40 CFR 21(d I am a large quantity generator)or(b)(if I a II quantity generator)is We. <br /> Gentedlfyped Name SynaWre _ Month Day Year <br /> neretorsl rors Pn <br /> aq 16 <br /> .� 16.InternationaMthipfflents <br /> F ❑Import to U.B. Export from U.S. Portof enbylexit: <br /> z Transporter signature(for exports only): Date leaving .5.: <br /> 17.Transporter cknowledgment of Receipt of Materials <br /> � Transporter 1 P tedRyped Name �, Signature Z Month Day Year- <br /> 4 1 loci 17,q 1 /15 <br /> GTransporter 2 PnntedfTyped Name Signature Monty Day Year <br /> C <br /> F <br /> ♦ 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity, ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manffest Reference Number. <br /> 18b.Altamate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL FacilN/s Phone: <br /> W i8c.SignatureofAltemate Facility(or Generator) Monty Day Year <br /> Q <br /> 2 <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and reading systems) <br /> C3 1' 2. 9. 4, <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlT Same Signa M Day Year <br /> EPA Form 8700-22(Re/,_v 3-05) Previous eadions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 1)651/156030 <br />