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SSL SK SHIP# 226352630 1111111111111111111111111111111111111 <br /> 0 0 6 3 9 1 5 9 1 S K 6 <br /> Please print or We.(Form des' rued for 'son elite(32-pitch) pewriter.) Form Approved.OMB No.205H039 <br /> UNIFORM HAZARDOUS 1.GenerelerlD Number 2."'Sof <br /> ej of 3. ma R P 4.Manifest TrackingNumber <br /> WASTE MANIFEST CRD982485351 �� -���- �� 1006391591 SKS <br /> 5.Generators Name and MailingAddress Generators Site Address(It different than meting address) <br /> Cal—Trans Shop 10— Lodi Cws <br /> 845 E Pine St <br /> LODI CR 95240-3108 <br /> Derivatives Phone: 209-333-6953 <br /> 5'T%Wfff — 'C M SYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 0.Designated Fadtily Name Bw Site Address SAFETY—KLEEN OF CALIFORNIA U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK , CA 94560 <br /> Si0-795-4400 CRD980887;•1$ <br /> FacitiNs Phone: <br /> 9a, 910.U.S.DOTDesaipton Including Proper Shipping Name,Hazard Class,ID Number. 10.Canhaineis 11.Total 12.Unit <br /> HNI and Packing Group(if any)) No. Typs Quantity wiivol. 13.Waste Codes <br /> NON RCRA HAZARDOUS WASTE,LIQUID TT G 133 '' <br /> ETHYLENE GLYCOL SOLUTION (LESS THAN 50.) <br /> Oc71 .S <br /> z z. <br /> w <br /> 3. <br /> 4. <br /> 14,Special Handling msbumons and Additional Information TSD:EVG 77803257 CA47958 201835 CSG:1 <br /> 24H EOIERGENCY#800-468-1760—CHJSKITFI—Contract retained 6y generator confers a e. <br /> an initial transporter to add or substitute additionaltrans otters on enera <br /> 15. GENERATOWS(OFFEROR'S CERTIFICATION:I hereby declare that mawlenta of this consignment am folly and aaurawly desclLed above by the proper shpphg whoa,and are classified,packaged. <br /> marked and labeladlplacarded,and are in at respects in proper condition lot bawport according to applicable International and national govemmenlal regulations.If sx7lod shipment and I am the Primary <br /> Exporter,I certify that the consents of this consignment conform to the lens of the attached EPA Actu avledgment of Consent <br /> I cerOfythat the waste minimization statement identified in 40 CFR 262.27(e)(ff l am a large quantity generator)or IS)(if I am as ti qusnfity gamerator)is tore. <br /> Gerkm�fr rORerors PrinledrTyped Name_ 5�urrelora z Monro 'Day Year <br /> 1 .Intearetiawl hipmsnls - r <br /> ❑import to U.S. ❑Fxporltmm U.S. Paidat entryle <br /> Transporter signature(for exports only): Date leaving <br /> 17.Tmnsp rWAcknoMedgmentof ReceiplofMaterials <br /> Transporter 1 dmedfTyped Name Sigwhxe Month Day Year Year <br /> Q. <br /> (— f j lots Ort /0 <br /> Transporter PnnteWyW Name Signature Month Day Year <br /> K <br /> 18.Discrepancy <br /> 18a.Discrepancylndiralion Space ❑ ouantiy ❑T a ❑Residue El Rejection <br /> yp J ❑Full Rejection <br /> Manifest Referanum Number <br /> I Bb.Alternate Facility,for Generator) U.S.EPA ID Number <br /> U <br /> LL Faciliys Phone: <br /> 1&.SigwWre ofAltemate Fadtity(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Haurdous Waste Report Management Method Codes 0.e.,codes for hazardowvrdste insentient,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Facility Owner .orOpermor.Gemination of mceglt of hazandous materials covered by the manges!except as Mad in Item 18a <br /> VIII Pnntedfryped Name Signature Month Day Year <br /> EPAiFp ,J3Y-jMW,VS) Previouseditionsare obsolete. DESIGNATED FACILITYTO DESTINATION STATE(IF REQUIRED) <br />