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SSL SK SHIP# 227268083 I�II��I li)����(I�IIIIIII�IIIIIIII�III <br /> 0067756196 K3 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number 2.Page of 3. m R e 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> TxR0t800812051006775619 SKS <br /> 5.General Name and Mail in Adtlress Generators Site Address((d d'dferenl than mailin address) <br /> SAFETY—KLEEl 5Y5TEMS, INC. SAFETY—FfLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95369 <br /> Generators Phone: 209-545-1011 SALIDA CA 95369 <br /> 6.TtWtt?—"Rt'ftN SYSTEMS INC U.S.EPA to Numbar TX R000081205 <br /> 7.Transporter 2 Com an Name U.S.EPAID Number <br /> CLEAN HFAFBORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> 8.Designated Facifily Name and siteAddress THERMO FLUIDS INC U.S.EPA ID Number <br /> 12533 SE CARPENTER DR <br /> CLACKAMAS , OR 97015-19989 <br /> 503-788-4fi16 ORQ000®25197 <br /> Facility's Pherte: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) t3.Waste Codes <br /> No. Type Quantity WLNvI. <br /> 1. NON—RCRA HAZARDOUS WASTE SOLID DM P 223 <br /> 0 (DRAINED/UNDRAINED USED bIL FILTERS) <br /> � � ZJC'7Cx� <br /> w <br /> Z2 <br /> U.1 <br /> C7 <br /> 3 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD;TPO SAL CSFs: <br /> 24H EMERGENCY#SN-468-1760—CH/SK/TFI—Contract retained by generator confers agyency authori y <br /> on initial transporter to add or substitute additional trans orters on enerator's behalf. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:f hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeiedlplacarded,and are in all respects in propercondition for transport according to applicable International and national governmental regulations.If expert shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)if I am a large quantity gene! b)(Ill am a small tty generator)is true. <br /> LuallIvAlaffaroest"MKOyopt!Name 'nature Month Day Year <br /> � <br /> 1. ematlonal Shipme <br /> H ❑import to U.S. ❑Export from U.s. Port of entrylexit: <br /> ? Transporter signature(forexports only): Date leaving U.S.: <br /> Of 17,TranspoderAcknowEedgment of Receipt of Materials <br /> LU <br /> C T spo r i PrinledlTyped y�1y�� 1 I 5' re Month �Day <br /> Year <br /> 0 '� • x C/ C f v t <br /> a <br /> QZ porter2 Pdnted(T ame S /lam Month �iDay Year <br /> 18.Discrepancy <br /> 18a.Discrepancy indicaton Space ❑Quantity ❑Type ❑Residue ❑Partial j ❑Full Rejection <br /> Reaction <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) LLS.EPA ID Number <br /> 3 <br /> U <br /> tai Factlity'5 Phone. <br /> ISc.Signature of Alternate Facility(or Generator) Month Day Year <br /> t— <br /> d <br /> Z <br /> Uj19,Hazardous Waste Report Management Method Codes(Le,codes for hazardous waste treatment,disposal,and recycling systems) <br /> a 1. L 2. 3. 4. <br /> 20.Designated Facility Ownero Operator Certifi.t-of receipt of hazardous materials covered by the manifest except as noted in Item <br /> PdrdetlfiypedName— Signa Month Day Year <br /> 7 117 <br /> ev' s editions are obsolete. SICNATED F LITY TO EPYs e-MANIFEST SYSTEM <br />