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: SK SHIP# 225541717 Please print or type. (Form designed for use on elite (12 -Ditch) tvoewhter.) Ill�ll�li Il�llillll�ll� f �I�� I SII Ifs 0065208015K5 Fnrm Annrnvarl OMR Nn 9(15f1-nnq EPA Form 81UG-22 (Rev. 3-05) Previous editions are obsolete. 1!'78rcFiF,%1—.560 _; DtOIGNATED FAtILITYTO DESTINATION STATE (IF REQUIRED) Page 30 UNIFORM HAZARDOUS 1. Generator Ip Number T xC�=�Z�A 1 0!-!,cF Z Pag of 3. Emergency Response Phone i.;_. 4. Manifest Man €festTrrackiNumber ( WASTE MANIFEST OO6 V O V V 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) SAFETY--KLEEN SYSTEMS, INC. S€ FETY-KLEEN SYSTEMS, INC. PO BOX 555�+ 5+ 50 SAL I DA BLVD A 9536a Generator's Phone: SAL I Aj ;F 95368 6. Transporter 1 Company Name U.S. EPA ID Number SAFETY-KLFIwN SYSTEMS INC �� TYR000081205 7. Transporter 2 Company Name U.S. EPA ID Number ENVIRf3NME1 TAL 5V` i! NC. iiRD@3 32217- '50 A. Designated Facility Name and Site Address TNER�![1 FLUIDS INC U.S. EPA ID Number 12533 SE CARPENTER DR CE_ACKAMAS , OR �7�1i �-8�8�� 5 13-7 38-461 fs ORG000025197 Facility's Phone: ga. 9b. U -S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 3. Waste Codes No. Type HM and Packing Group (if any)) quantity Wt.Nol. 1 NON—RCRA HA?iRDClitS WASTE SOLID P 223 (DRRINEptl1`dDRAIiiE1) EISEDbIL FILTERS) z 2. ua 3. - 4. i 14. Special Handling instructions and Addilional Information TSD : TPC1 ^At.. CSF 24 Fitt EMERGENCY ##1 -BOO -468-4760 (CH / SK I TEI) %1T IlC ii - IPa C.t,. 15 GEkRATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignmertt are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeiedlpiacarded, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (it I am a large quantity generator) or (b am a small quantity generator) is true. G re eslOfferoes Pd !Typed Name Signature Month D Year J H 16.Int aticnal hipments ❑ Import to U.S. ❑Export from U.S, ort of trylexit: Transporte Lure (for exports only),Dv€ng U.S.: W 17, Transporter Acknowledgment of Receipt of Materials ETra er 1 Prinledf yped a Signatur Mo th y o /Year in. rn / QTra porter Printed yped Na Signature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space Quantity ❑Type 1:1 Residue ❑Partial Rejection 1:1 Full Rejection Manifest Reference Number: 18b. Alternate FaciYity (or Generator) U.S. EPA ID Number J U u< Facility's Phone: 4, w 1 Be. Signature of Alternate Facility (or Generator) MonthDay Year a Z 19. Hazardous Waste Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) jR�eeport I_i 1 2. 3. 4. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest exce not in Item 8a 44 Printedrryped Signature Mo Day Yeaarr' s I(I rte. ja "'" EPA Form 81UG-22 (Rev. 3-05) Previous editions are obsolete. 1!'78rcFiF,%1—.560 _; DtOIGNATED FAtILITYTO DESTINATION STATE (IF REQUIRED) Page 30