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SSL SK SHIP# 2-2-5352830 II�IIIIII1IIIIIi1IIIIIIf1IINIII IIII 0 0 6 3 9 1 5 9 1 S K 6 Please print or type.(Form designed for ttse on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARI)OU5 1 Generator 0 Number 2.Page of 3. me R e P 4.Manifest Tracking Number WASTE MANIFEST C R�9�2``�5 3 5 1 � ,� � �-��- �� 1006391591 SKS S.Generators Name and Mailing Address Generator's Site Address(it different than mailing address) Cal-Trans Shap I@-- Lodi Cws 84-�5-y E Fine St /,7 I_ODI ___ _ CA 95240-3108 Generator's Phone, 209-333-69'_5 3 s.Tr�lgsaprti tV-M'�� SYSTEMS INC .S.EPR ID Number OO C TXROOB1205 7.Transporter 2 Company Name U.S.EPA ID Number 8.oesignaled Facility Name and Site Address SAFI=T Y-KLEEN OF :-AL I FO RN I A U.S.EPA to Number 68801 SMITH AVE. _ NEWARKe CA 94560510--7` 5-4400 CAD980887�1.18 F2cif:ty's Phone: ea 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 113 Waste Codes Hf.e and Packing Group(if any)) No Type Quantity WIN01. 1. NON RCRA HAZARDOUS idASTE,I_TOUID TT 133 o ETHYLENE GLYCOL SOLUTION (LESS T HIPI 150%) 2-Y 2 2. LU t� 3. 4. 14.Special Handling Instructions and Additional Information TSD:HVG 77812132S7 CA47958 201835 CSG i i 4H E4�#ERGEfUCY 0k�-�rEB- 17EC:-CH:SKIiF+-Coil{ r�act retained by r�net;ator E onfers a Vs on initial transporter to add or substitute additional toanS orters on . 6Ttet'a o 19. GENERATOR'SlOFfEROR'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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemalionaland national govemmenlat 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)(H I am a large quan8ty generator)or(b)(if)am a s II quantity generator)is we. Genera t Offerors PrintediTyped Named Si r Month Day Year 1 International Shipments " T; ❑Import to U-S_ ❑Exportfrom U.S. Port of entryle Z Transporter signature(for exports only): Date leaving � 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 rinledlTyped Namme Signature klonllhh 77Day Year T:ansperier 2 PrinledlTyped Name Signature Month Day Year I-- 18.i3lsctepancy I 8a.Discrepancy indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fu4 Rejection Manifest Reference Number 18h.Alternate Facility(or Generator) U.S.EPA ID Nomber J U W Facility's Phone: y©y Ift Signature of Alternate Facility(or Generator) Mon h Day Year a z 19.Hazardous Waste Report Management Method Codes(+.e.,codes for hazardous waste treatment,disposal,and recycling systems) © 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Elem 18a PdnledlTyped Name Signature Month Day Year 'PAiFp $ O9 �x 1) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)