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"c: �1: ^HTFit ^^4J.�A1��, �� IIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIII Please print or type.(Form designed for use on elite(12-pitch)typewriter.) D OForm Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone_ 4.Manifest Tracking Number WASTE MANIFEST �001Ic0A!'2135 1006285801 O ^ O KS 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address)L CR 95.'•58 Generator's Phone: "-a —ry+c'-1@11 SRLIDR 6.ltmpprter 1 Company Name U.S.EPA ID Number �] -'TFMS INC 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA U.S.EPA ID Number 6880 SMITH AVE, NEWARK CA 94560 510—?95 4rs00 CAD98R8A?/•, Fadlit>'s Phone: 9a 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(it any)) No. Type Quantity WVJd. 4:^_-.Tr" 1_J'�IJI O r"'ll -QI iii CY;t� THF'Pl `_i4�IX1 r 13.E w001 V z 2 w 0 3. 4. 14.Special Handling Instructions and Additional Information - 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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.H export shipment and I am the Primary Exporter,I certXy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Com en I modify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I a smallnmy generator)is We. Generru ears PrintedRyped Name Signature Month Day Year 101 17-7- 1 /9 1 (shipments 2 ❑Import to U.S. ❑Export from U.S. r of antrylexN: Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter cknowledgment of Reiof Materials K Transporter 1 nnmcUTyped Name ' Signature Month Day Year y o l L2 1 z Transporter Printeciriyped Name Signature Month Day Year K r t18.Discrepancy the Discrepancy Indication Space ElQuantity ❑Type ElResidue ElPartial Rejection ElFull Rejsi Manifest Reference Number: 1all.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: ou 18c.Signature of Alternate Facility(or Generator) Month Day Year z Z vi; 19.Hazardous Waste Repo Management Method Codes(i.e.,codes kr hazardous waste treatment,disposal,and recycling systems) G 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 PdnledrTyped NameP�y1.,, _ Signature Month �DDay Year\ J/'i//K✓� G-. y EPA FORn,l. e.3-05) Previous actions are obsolete. DESIGNATED FACT ITYTO DESTINATION STAT (IF REQUIRED)