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RECEIVED BY SJCEHD (EF) ON 2/5/19 E(E <br /> 132"'- +7R <br /> Please print or type.(Form designed for use on elite 12,-pitch)typewriter.) d 0 5 b 3 9 7 7 Q S K 5 <br /> ( fS Farm Approved.OMB ND.205MO39 <br /> UNIFURIUf HAZARNQUS I.Generator IC Number r C 2,Pap I of 3.1_ Phgne 4.ManifQst TtacEdng Number <br /> WASTE MANIFEST CA09824t�-��i �� oss3i7o SKS <br /> Generators Name and MaiingAddress Ganaratn s G1eAddreSs fn Cllferant than mailing address) <br /> C41 -TrafiS rhOP 10— Lodi <br /> i6033 S B StCarl—Traps Shop 'io— 1-ll.;. <br /> S rou rom CA 9SZ0x5 84S E Pine St <br /> G*narators Phcvta: 209-333-6953 <br /> S t EMSS.EPA ifl humt32s <br /> 1 TKRO00084- Fa <br /> 7.Transporter 2 Company Name <br /> U.S:EPA€D Number <br /> a.DesignotedFaralify garneandSite Address SAFETY—KLEyEN SYSTEMS1 IHC U.S.EPA€1)Number <br /> 6000 88TH STREET <br /> SACRAMENTO CA 7S828 <br /> lPhone: CA0 00 084SJ <br /> 9a. 9b.U.S.DGT Descripiron turdt4l Proper Shipping Name.Hazard Class,ID Number.. <br /> and Pa y 10.Cantainera <br /> Hkt �9 G fd any)) <br /> t 1.Total 12 unit 13.waste Coles <br /> 1. <br /> No. Type 4vantity WINol.t?Q#�—RC1�tA HAZARDOUS WASTE, LIQU"sD � <br /> o (AGUEOUS DRAKE CLEANER) <br /> z 2. Nt1h1—RCRA P AZARDOUS L C QlI1 t) D f' <br /> (AQUEOUS PARTS WASHES; SOLUTION) <br /> 3. <br /> a. <br /> F <br /> i <br /> 14.Special"al ins!nrctionsand Addit rtalinfumta!ion TSD: SCA 71158,;4 CA3709 201651 CSt~'t:z1;' <br /> t.f HK Eh EROEN ,' #1-800-468--1760 (SK ! TI"Y) <br /> AU H t'l'� "AGEN1---FCF.,, BY GEM TO RETAIN LICENSED SUP CARRIERS f�5 SCE <br /> 15. GENERATOR'SWFEROR'S CERTIFICAT*N:1 hereby declare that the contents of this consignment are fully and accurately desethad above by the prover shipping name.and are classified:pa(;k d: <br /> marked and labeledlpiacarded.and are in all respects in proper oondition for hang rt accordi to a I cable intamainnaf and naGond <br /> p0 Pp govemmen!al reguWions.If export shiameril and I am the Frmary <br /> Exporter,I certify that the contents of this consignment conform to the tents of the at,ached E°AAnkrwv�edgmert of Consent.S c6rhfY U as the wWe minlrnv Wn statement irk-ntihad in AQ CFR 262.27(a)(f I am a large tptantil generator)oZ;O=. <br /> Generator'si0fferta's P7 edffyped Nww Signature <br /> Month Day Year <br /> B.Intemattona#Shipmenls c�r7C 1 1 7 <br /> Li 1 Impart to U_S. ❑Export from U,S. <br /> Transparter signatura(far exports on#y): <br /> Dale leavingv 5,: <br /> t?.Transporter At uvMedgment of Receipt of Materials <br /> T 1 Prin�dlTypad S:gnatu <br /> A{ tear <br /> Transport Pri edffypad Name Signal re Month nay Year <br /> i <br /> 18.ns+trepancy <br /> 188.Discrepancy Indication Space <br /> Quan>tty ❑TYP? P Residue Parfai.Rejsciion Fn€I Rejectan <br /> Manifest Reference NLmber: <br /> 1Atr.Alternate Fad€ty{or Generator} U.S.EPA IU Number <br /> f'? <br /> Facility's Phone <br /> iUj 1 Be.Signature of, Fac I y{or Generator) <br /> � ialortth Day Year <br /> .2 <br /> rn 19.Hazardous Waste Repo t Management Method Codes mdes'or hazardous wasle treatment,disposal,W recycling systems) <br /> LU <br /> t' Hi 4 1 2. H i 41 <br /> 20.Dasignated Facility Owner or Cperel Certifirz!ion of recrapt of hazardous mat8rials mverBd ay 110 man'IbS!except as rated in Item 188 <br /> rinled1Typed Name <br /> :=ni <br /> >C..�+ 5igrature e � Sionih Day Year <br /> E A 9 67c t5/ t�1 3 P " /� DESIG ATED FACILITY TO DESTWON SPATE(IF REQUIRED) <br />