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SSL 5K SHIP# 218333781 <br /> Illllllllllllllllllllllilllllllllllll <br /> 0 0 5 3 2 8 6 4 0 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Eg�y R��gp p Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.GeneratorlD%mber TXR000081205 2Pagllof 3,1—tl10if7-46tl�1/b� 4'MandestTraddn Number <br /> WASTE MANIFEST 0 0 5 3 8640 SKS <br /> 5.Generators Name and Mailing Address Generator's Site Address('d different than mailing address) <br /> SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN SYSTEMS, INC. <br /> PO PDX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209-545-1011 SALIDA CA 35368 <br /> 6.T {ter'i,�or�r�rw.filaare SYSTEMS, INC. U.S.EPA ID Number TXROOOOB1205 <br /> 7.Transporter <br /> t2rCompany <br /> Name U.S.EPA ID Number <br /> 8.Designated Facility Name and She Address SAFETY—KLEEN SYSTEMS, INC. U.S.EPA ID Number <br /> 5000 88TH STREET <br /> SACRAMENTO , CA 55828 <br /> 916-386-4913 CA0000084517 <br /> Facilil�s Phone: <br /> ga. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt-Nol. <br /> 1. <br /> o t <br /> �d <br /> z z. NON—RCRA HAZARDOUS WASTE LIQUID C� DM �� G 134 <br /> UJI <br /> (AQUEOUS PARTS WASHER SOLUTION) <br /> 3. <br /> ( ION) <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:SCA SAL + )4 SG: <br /> �cob��z3�1 <br /> 24 HR EMERGENCY #1-800-468-1760 (SK ! TFI) � I L66 l�CjCf7?� <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 Iabdaplacarded,and are in all respects in proper condition for transport according to applicable international and national govemmeMal regulations.If export shipment and I am the Primary <br /> Exporter,1 certify that the contents of this consignment conform to the tens of the attached EPA Acknowledgment of Consent. <br /> I cardly that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or am a small quantity ge tor)is true. <br /> Genera roes P'ntedlT Name SignatureM Day y <br /> -J 16.International Shipm is <br /> ❑Import to U.S. ❑Export from U.S. od of ntrylex8: <br /> Z <br /> Transporter sign�,.for exports only): Date avingU.S.: <br /> wU 17.Transporter Acknowledgment of Receipt of Materials <br /> �,8nprPnntedR N Signature nth aorter2PnntedlTy dName Signature Month Day Yea <br /> rY <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> u4- Fadlirys Phone: <br /> aW 18c.Signature of Alternate Facility(or Generator) Nbnth Day Year <br /> � Y <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,odes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1, � A / 2. H141 3' 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the man"except as noted in Item 18a <br /> Prin yped Name l n Signature f month [My Y <br /> EPA Form 700-22(Rev.3-05 Previous editions are obsolete. DESIGNATED FACILITYTO DESTINATION STATE(IF REQUIRED) <br /> P,y 2)14941!156023 34-_-- --. –F__ P< <br /> Page 20 <br />