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361_ SK SH111i 2247162241 111111111111 ISI II I� 11111111111 006587' 9394 KS Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID NumberCAL0003'S�(3931Errlttt�gpcyRespouse Phpne 4.MantfestTracking Number WASTE MANIFEST 0 0 6 5 8 7 9 3 9 SKS 5.Generator's Name and Mailing Address Generalor's Site Address(if different than mailing address) Rid Late Rubber Cts. Inc. 8830 W Linne Rd TRACY CA 99304-910? Generator's Phone: 209--836-0965 6.Tj"'�t`:L.CNe'S1STEMS INC U.S.EPA ID Number TXR00008120S 7.Transporter 2 Company Name Cr U.S,EPA ID Number ill -"1Gyf�( 8.Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS, INC US.EPA ID Number 6000 88TH STREET SACRAMENTO CA ?S828 916-•386-49131 CA0000OB451 f Facility's Phone: ga 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(if any)) No, Type Quantity W1.Nel. 1 NON-RCRA HAZARDOUS WASTE, LIQUID � Z� G 134 o (AQUEOUS PARTS WASHER SOLUTION) Z 2. Lu c� 3- 4. 14.Special Handling Instructions and Additional Information TSD: 5CA 76105119 RIJr 1542? 201810 CSI : 4A 24 HR EMERGENCY # 840--468�-1760(SAFETY-XLEEN) Dv-14-11 AUTH AS "AGENT-FOR" BY GEN TO RETAIN LICENSED SUB CAr'?"-,1ERS AS NECESSARY 15. GENERATOR'SfOFFEROR'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 labeiedlplacarded,and are in all respects in proper condition for transport according to applicabie intematonal 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 Acknow%dgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if 1 am a large quantity generator)or(b)(if I am small quantity generator)is true. Generator`slOfferars Printed[Typed Name 7ature Month Day Year 0 i`L ti , �, �3 13 IT ,,r 1 18.International Shipments ❑Import to U.S. Export from U.S. ort f enfrylexit: Transporter signature(for exports only): Date leaving U.S.: 17 Transporter Acknowledgment of Receipt of Materials UJI K Transporter 1 PrintedlTfy NEIrne Signature Month Daj Year a y�TY' N G �I�CrLr�Y .'V v i J i Z Transporter 2 Printed a arae Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ty ❑Type ❑ ❑Partial Re ❑Fuli Re' ❑ Quantity T Residue jection lection Manifest Reference Number: r 18b.Altemate Facility(or Generator) U.S.EPA ID Number U LL Facili Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q 2 7) 19.Hazardous Waste Report Management Method Codes(i e.,codes for hazardous waste treatment,disposal,and recycling systems) LU c 1. F1141 Z r 4. 20.Designated Facikity Owner or Operator:Certfcation of receipt of hazardous materials covered by the manifest except as ncled in Item 18a - nn d Na 0 1,, r _ Igfpth Day Ye EPA Fit-0700-22 ev.3 0�5} Previous editions are obsolete DESIG AT D FACILITY TO DESTINATION STATE(IF REQUIRED) 1Y41/1602.