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Please print or type. (Form designed for use on elite (12 -pitch) tymewriter.) <br />005947403SKS <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22�Rev.3.05 P�ouseditions are obsolete. DESIGNAT FACILITY TO DESTINATION STATE (IF REQUIRED) <br />Page 22 <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1 • Generator ID Number _ <br />.` 17 z �j1 <br />2. Page 1 of <br />t-1-7 <br />3. Em envy R se Phone <br />4. Manifest Tracking Number <br />1005947403 SKS <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />SP�AF'E�yTY--KLFEN SYLETE S, TNC. SAFETY [f SYSTEMS, 1.f�ll , <br />PC Br-1 1Aa <br />OX rC 705'0SA€._TDA BLVD <br />Fol <br />Generators Phone: 209--`4-j " 01 <br />6. Trans iter i Comtpan Name <br />U.S. EPA ID Number <br />SAFTy_ .1 _EI SYSTI='S INC <br />TXTft?Ii7t° 1 w?tA <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />.f_ _ <br />iCI EPIN HAR13ORS ENY I' PONIMIENTIPL SFRU I CE` -a T f;_f <br />8. Designated Facility Name and -Site Address THERMO FLUIDS T NC <br />U.S. EPA ID Number <br />4301 W jEFFERSON nT <br />Facility's Phone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13, Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />Ix <br />1 1`10IN--RCRA HAZARDOUS WASTE: S0t., lD <br />1}� <br />P <br />e, <br />qo <br />fDRATNED/U1`DRAINED USIE, (til._ '=I TErt.;�' <br />� <br />lob <br />z <br />2. <br />W <br />3. <br />4, <br />14. Special Handling Instructions and Additional Information Tpjr l} : TPA FSA ..yAi- <br />i.,C SC <br />r4 HR EMERGENCY #1-_800--46 - ��3� ;Ss; ,' 3FT <br />I.t.. 1[A s _ 3F r r• T C'y . �'} Ci I r n P, p T <br />15. GENERATOR'S10FFEROR'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 governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (If I am a large quantity generator) or (b) (if IAV a small quantity gen tor) is true. <br />raf0lferors Pafryped Name Signature <br />Month Year <br />TZ <br />%Day <br />N <br />-A <br />F <br />16. intern 'anal ipments <br />❑ Import to U.S. ❑ Export from U.S. P of ent e)it: <br />Z <br />Transporter si ture (for exports only): D leavi U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />a <br />T er 1 Printedff Name Signatu <br />Day <br />a <br />W <br />r/ <br />QTra <br />sport 2 Prin Name Signature <br />Month Day Year <br />, J <br />!Vi N Tom'41 <br />16. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantityy <br />❑ Type esidue <br />Partial Rejection <br />j <br />❑Full Rejection <br />Manifest Reference Number <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J_ <br />C? <br />FacilVs Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems) <br />G <br />1. <br />2. <br />3. <br />4. <br />20. Designated Facility Own Aerator: Certification of !2 t of hazardous materials covered by the manifest except as noted in Item 18a <br />Printedfryped Name / S gnature <br />Month y_ Y <br />EPA Form 8700-22�Rev.3.05 P�ouseditions are obsolete. DESIGNAT FACILITY TO DESTINATION STATE (IF REQUIRED) <br />Page 22 <br />