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Please print artype.(Form designed for use an elite{12•pifctl}typewriter.] Form Approved.OMB Na.2050-0039—T4—.M <br /> 050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manlfe T; kl g m r [�j SKS_WASTE MANIFEST Li l)9F3i?�r9 ih 13 i I -1`31010. 4GA--1"160 051 5 C? S KV <br /> 3.Gen&itoes Name and Mailing Address Generator's Site Address(I different than mailing address) <br /> �f�Y'�l�s 1k' if��l_� t���nk) ;�f►.ti"r,ttit� ILI (Tr'acy-' Maim'-.) <br /> STOCK TON CA 95206 <br /> GeneratvdsPhone: TRACY CA 95377-q1:J0 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> r1`F F'F`e--K LEEN SYSTEMS, INC, TX R0Q:0081 c`TtC`_ 4 <br /> 7,Transporter 2 Company Name U. ID Number <br /> S-Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS, INC. U.S.EPA IDNumber <br /> 6000 88TH STREET- t <br /> SrACRnMENTO , CP 9`829 <br /> Facility's"hone: <br /> ga, gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)] N3. Type Ouartity Vdl.Npl. <br /> NrJN--RCRA HAZARDOUS WASTE, 1..IOLI'D (int <br /> o (AQUE005 PARTS WASHER SOLUTION) 1 <br /> 2 l <br /> 0 2 i~ <br /> I <br /> V V LUW , <br /> f ' Wyr <br /> A . <br /> 14.Special Handling lnstmclions and Additional Information <br /> 24 HR ENERSENCY 01-800--468-1760 CSK 7 TFI) <br /> !!r_' L r]C u # rT pit V r2 h T_ R F YT•. rCL' Amp _C?C c. cFC tCr'N <br /> 5- GENERAT4R'SlDFFEROR'S CERTIFICATTpN: I hereby declare fh2f the contents of this consignment are fu11y and aecuraleiy described`above Iiy the proper shipping name,a are vl mss d,packaged, <br /> marked and labeledjplacarded,and are in aIf respells in proper condition for transport aaArding Ie applicable infemabon at and national governmental regulations.If export shipment and I am the Pnrnary di <br /> Exporter.I cartify that the contents of this consignment ccnferm to the terms of the attached EPAAcknowledgment of Consent. _+ <br /> I certify that the waste minimization statement identified m 0 CFR 262.27(a)(if I am a large quant ty generator]or(b)(if I am a small quantity genarator�is tNe <br /> Genemro�slOfl rat's Prin d Name 1 j 1Jronth Da Year' <br /> J 51gna y <br /> ).•err . �f r ` � ��3a_.�f F L ..�=�-�c.-l��..�.��� l <br /> _j 16.Inlernational5hipmen �-f_2911exslt.❑Import to U,S. ❑Export from U.S. PoTransporter signature(for exports only): Da ^x <br /> Li <br /> 17_Transporter Acknowledgment of Receipt of Materials ' <br /> OTr�er 1 P6tec7yped Name Signature Mon h Da; Year <br /> Trans crier 2 Pr ntedlTyped Name Signature <br /> er r Month Day Year <br /> lij SIT <br /> 18-Discrepancy <br /> 18a Discrepancy Irdreahon Space <br /> ❑ Ouantiry, ❑Type ❑Residue ❑Patal Rejection ❑Fun ReI�.o, <br /> rSanifest Referaxa Number: _ <br /> 18b AIlemate Fadtiry{or Generator} V.S.EPA ID Number <br /> U <br /> FacAYs Phone: <br /> Lul18c S gn3brre of Altemare Facility(or GeneralwJ <br /> a <br /> rYlcrrh Ca, Yeor <br /> z <br /> w19.Hazardous'/haste Report Managemenl Method Codes(i.e..codes for hazardous waste treatment,disposal,and recyd ng systems} <br /> fm t 2. 3 <br /> H1.4 I 4. <br /> 217. segnafed Facility pv?r2r or Operator Ceftif€cal on p1`receipt of hazardous materials covered by the manifest except as haled in Item i <br /> Pr�eame <br /> [ , ,e �,• lutlonin Cray Year <br /> cPA term 8700-22(Rev. 5) Previous editions are cbsolete. E { 1 raj <br /> 1 R 1'+941 /1- i..- DESIGNATED FACILITY TO GENERAT <br />