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��=t - �QP� IIIIIIIIIIIIIIIIIIIIIIIII <br /> 0062557923 K5 <br /> Please pant or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number TX i< __ 2.Page l of 3.Emergency Response Phone. 4.Manifest Tro M Number <br /> WASTE MANIFEST 006265792 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(If different than mailing address) <br /> "STEMS, INC. <br /> CA 95368 <br /> Generator's Phone: 209-545-1011 Spit, T r.^- <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <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 SMTTH AVE. <br /> 510-795-4400 NEWARK , CA 94560 <br /> Paull Phone: <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 Pill Group(If mi No. Type Quantity Wi <br /> 1NON RCRA HAZARDOUS WASTE,LIDUID <br /> o ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) <br /> = 2. <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:FVG ' <br /> 'R !rtvrcarrcn--•i tFt ^.t*m -%X.�3..1'1<'.(t -nr <br /> Ir- <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 international and national gove mental egulabons.If export shipment and I am the Primary <br /> Exporter,I certity that the contents of this consignment conform to the terns of the attached EPAAcknowledgment of Consent. <br /> certify that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large pull generator)or(b)(III am a small quanti ganer or)is We. <br /> Generaturst0lf cors Printed/rypedNcme Signature Monts Day Year <br /> L o7 <br /> 16.International Shipments <br /> i- It 7 <br /> Import to U.S. ❑Fxpod from US. Pad of entrylez <br /> Transporter signature(fair exports only): Date leavinge. <br /> fill 17.Transporter Acknowledgment of Receipt of Materials <br /> Transported nted/Typad Name Signature Month Day Year <br /> N Z 107 It7 <br /> Q Tran er n Name Signature Month Day Year <br /> C <br /> F <br /> I <br /> 18.Discrepancy <br /> 18a.Discrepancy lndiration Space ❑ Quanfity ❑T pe <br /> y ❑Residue ❑Partial Rejectlon El Full Rejection <br /> Manifest Reference Number: <br /> 181h.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> UL Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Ne <br /> 2 <br /> H19.Hazardous Waste RkI1eport Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> L <br /> 20.Designated Facility Owner or Operator.Certificafion of receipt of hazardous materials covered by the manifest except as noted m 18a <br /> Pnntedrfyped Name Signature Month Day Year <br /> 111 IQ 7 117 <br /> EPA Form 870 -22(Rev.3-05) us editions akobsolete. DESfGl FACILITY TO DESTINATION STATE(IF REQUIRED) <br />