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SSL SK SHIP# 223017066 , <br /> Form Approved.ON18 No.2050-0039 <br /> Please print ortype.(Form designed for use on elite(12-pitchy typewdler,} <br /> 4.Manifest Tracking Number <br /> 1.Generator 15 Number 2.Page 1 of 3.Eme envy Response Phone �� <br /> UNIFORM HAZARDOUS ��2/}�7$�$ 11. 1-8�0 466-176 <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Caltrans 10 (Tracy- Maint) .w,,�altrans 10 (Tracy- Plaint) <br /> 16103 S 8 St 2005 Krohn Rd <br /> STIOCKTON CA 95206 CA 95377-9120 <br /> Generator's Phone: 209-835'-6779 TRACY <br /> U.S.EPA ID Number <br /> 6',Transperter 1 Company Name TX 8000081205 <br /> SA ETY--KLEEN SYSTEMS INC <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC, �1ATi�13'�;��?2STd <br /> 8.Designated Fablity Name and StteAddress U.S.EPA ID Number <br /> SAFETY-•l`(LEEN SYSTEMS, INC. <br /> 60130 88TH STREET <br /> SACRAMENTO , CA 35828 CA@000084517 <br /> 916--.86-x+913 <br /> Fadlity�s Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nal. <br /> re 'NON-RCRA HAZARDOUS WASTE LTGUID LIM -PZ*' 134 <br /> (Al2UEOUS PARTS WASHER 5OLUTiON) � Z0 <br /> Z 2. <br /> u3 <br /> CD <br /> 4 <br /> 14.Special Handling Instructions and Additenal information <br /> TSD;SCA 73303540 CA3 1066 CSG <br /> 24 HR EMERGENCY ##1-8100-468-1760 (SK / TEI) <br /> I rr r rr MYa I f~ 97Rq <br /> �Jf �VIJ <br /> ib. GEN ERATOR'SIOFFEROR'S CERTIFICATION: [hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,aryl are Classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper conditon for transport according to applicable intematonal and n mental regulations.If export shipment and i am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Con <br /> I certify that the waste minir lEon statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)al(i am a small quantity tor)is true. <br /> Generators mrors . j ypad Name Signature Month <br /> mDay Year <br /> f A I <br /> � S6,inleational Sh1p is b 2S` <br /> ❑import to U.S. Export from U.S. Port a en lexit <br /> z Transporte55Egnature_{for ezppEt9 only): Dale leaving U.S.: <br /> Ill 11.TragsoorterAcknoMedg4rlReceipt ofMaterals <br /> . d O Transporterl prtnteType <br /> ell <br /> d Name Signature <br /> Month Day Year. <br /> cr . . <br /> Tra 2 P tEl Name <br /> Signature y <br /> Month Da Year <br /> i8. s repancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type <br /> i ❑Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> H­ f 8h.ARemate Facility(or Generator) Y Manifest Reference Number: <br /> 2-. U.S.EPA 17 Number <br /> LL FacilRys Phone: <br /> LU 1 ac.Signature of Alternate Facility(or Generator) <br /> a <br /> Month Day Year <br /> W 19.Hazardous Waste Report Management Methl Codes{i.e <br /> W cycling.,codes for hazardous waste treatment,disposal,and resystems) <br /> 2. 3.f <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrnteC�ypedName <br /> ) 5igriature <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. r MonN Day Year <br /> l-�", r. r � �� �+ r. <br /> 1} 14�k-1 115Es�3 ,: .r f <br /> CESIGNATElFACILITY TO GENERATOR <br />