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bZIL . kiM SHI P#R 2c,.5275,139' <br />Haase nH it nr tuna. f--. — mi- r, o ..__.. —__ , <br />uilil�il t�tllllm�ll�ifl�flllll� 111 <br />046<5'205'4'9SK'5< <br />Form Approved. OM9 No. 2050-003`: <br />UNIFORM HAZARaOUS 1. Generator lo,Numder r --' 2: pogo 1 of 3: Eme enc. Response phone 4. Manifest Trac ip�N.umher /� [� �+ <br />WASTE MANIFEST > xiG1s+07$ 2%� i i-FJ�a^4GA <br />L» �F J ' a7 K� <br />5. Ganemtors Name and Mailing Address GenerplcPs Sita Address tlfdiflerenldtan mailtngaddress) -' <br />SAFETY.-HLEEN SYSTEMS, ] NC, SAFE T't-KLEEhf 5YS'CE�35, INC. <br />pa Box 555 <br />5050 SALIDA . i LVL) <br />SALIDA GA 95368 <br />-. <br />Generators Phone -- c�9-5'�15-1Cf+].'I SAL.IItA.. <br />- <br />..'mirahsponarlcompanyNanae. - :.:.U.S,.EPAIONumber .. <br />5A€i:TY-r XvsTes r.!r. <br />rx�34iP�t�€�#15 <br />7. Transporiv 2 Compeny Name - - U.S: EPA ID Number -- <br />B. Designated Paa6tyName andSileAddrossSPFETY-KLEEN OF CAL,IhURNI€!- D.S. EPAIDNuaibe, _ <br />CHO:SMITH AVE. <br />NEWARK Lo9ta�t,o <br />400-' 7 <br />Facilitys Phone. - '. CAD980887.418 ' <br />9a. <br />gh. U S. OOT Oemipam (nvcludng Proper Shipping Mine, Hazard Class, 10 Number, <br />10. Conlainers <br />ii- <br />12 Unit <br />HMand <br />Packfng Gmvp (tt egy)j ` <br />.Taial <br />- Quantity <br />WtNaL. <br />13: -Waste Codes <br />.- . <br />No. <br />Type: <br />o <br />1: 'WoN-RCRA € UARDOUS WASTE, 1-10UID <br />TT <br />L <br />P l I <br />(USED. 01L) <br />r. <br />W <br />x <br />LIJ <br />2..: <br />f <br />14. Special Handling lnstn:Oons and Addikits! lnfirmailon SAS _ - ESUS _ .. <br />-. <br />24 SIR EMERGENCY ##:]-E4�t�-45FS-,7G0 t�H J 5! ./ TFi3 <br />„ lispu <br />t SlIB <br />'t'OPFEROA9$.CERT.IFIGATtON: <br />i5; GENERATOR I heraby daclara Ural the contents of this consignment are Nily endaaurately:de$a:rihedatxsvo by the prapershlyping name, and aro dassifled;.pac*ad, <br />marked and labeledlpiacardsd, and am in all resped5 in proper cand&n for Imfoport accoiding lo:applicableintematanaland naU'adat gevsWentaf requlations:lf export shinmarlt and j am the Prlmary - <br />Expoiter,icertdyttralieconlenlsofipiscoasignmentconromitatirratermsofiheadachedEPAAckwoivledgmento#Co nt..-- <br />t:camlythattha%%ogle.mWnrizalicn slatemenlidenUPed in 40 CFR 26227(ajIII am a large quariuty generator)or (U}j m,. ilquanbig_generalorjI's true. - <br />GaoeralorrJO erorsPinwe gdName- - 5lgnahira- - - _ - :hianth - Dar Year <br />—u <br />f- <br />161nternalionalShipments <br />❑ Import to iJ s. ❑Export from 5 Pon enbylexil <br />Z <br />of _ <br />Transporter signature (for exporls.pnlV3r. Date leaving u 5.. <br />rr. TianspsderAeknowledgment of Receipt V Materials - <br />- ..ate. <br />TransPoliei 1iPd !Typed Name e.:.r. - - 5i mature Month Oay. Year <br />W f <br />-' - - `.. <br />z <br />Trans er PdnledJT d.Name <br />3> yGe Signature MonthDay Year <br />18.DisCrePanry - .. <br />lea.. Discrepancy lgdiratipn space ❑ wlariuly ❑ Typo ❑ Residua D.PadiaE Rejecfian - Q <br />. - - FW Rejection <br />Manifest Reference Number_ <br />18b.A19mi to Facility (or. GdwWorj U:S. EPA IO Number -- <br />LL <br />Fad{iiy!s Plioper. <br />Lu <br />18c. Signaiore ofAternaEe Fagidy (or Gerierator) - - - <br />Month- DAy Year <br />a <br />z <br />19: Hazardous 1vasle Report Managemem McUwd.Wu$ (i.e, codes for hazardous waste trealmer disposal; andretyding systems) <br />20.DasigriatedFaaiityarmerorpperalor:.CemfrcaUonofracelptofhazatdousmaterialscovered bythe manile5text* lasnotedinbrinl5a <br />Pnnlerlfi Name Sgnatu Mamh.Yoar <br />