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12/01/2004 16:50 9404835 SAFETY KLEEN PAGE 03/04
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<br />ONjVf,COF4M1AS1ON
<br />RONMP QUALITY
<br />P.O. Box 1
<br />Austin, Texas 70711-3087
<br />Please print or type. (Farm designed for uw on eiit0 0 ptth'typewriter.} Form AQprova6. OMB No. 2050066,
<br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Mangy 2. Page 1 Information in the shaded areas
<br />WAS MAMIPEST C AR A O h CAO 103 2 ,f °f 1 ie not required by Federal 1®w.
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<br />3. Generator's Name and Mailing �/A4d tis `- $'' •r ! ?%4 f q `
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<br />PO BOX !849 .I::
<br />STOCKTO14 CA 952OA-i$4.g Rl"i . gWUt w:';:~:•",�' i'°" "
<br />209 54`T"1
<br />4. Generator's Phone t ,l' r:r-^,• u:r
<br />5. Transporter 1 Company Name •g��i r 6. US EPA ID NumiSer C.. 1�r. !)r�..''
<br />SA[ 4 Jc Y -J��aEEN SYSI'R' MS , .4�!. C . '� iR_ 00005019 J0• ®+.' r i :J'� ff p ' i.1,
<br />S US EPA ID Numbar ®� :'1.'''Y ' YIiPIE P• fn. r,
<br />7. Transporter 2 Company Name
<br />22M CCa&S--Ad1"
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<br />a. Hated Facilittyy Name and Site Address VIJ . � t o. US EPA)D Number qq�� �►• ;i' ',. � ; .; i ;�' � �(!' a y
<br />S e�TY-YLEEN SYSTEMS, 6r i' t,+'i+i '',';r �, t?5•�
<br />c r,• -� a •�'t' , lir 1 I r�4 � • !r`•+' �' .
<br />•1,722 COOPER C.Ri'.eQ..ely.q. ROADX 76206 TXDO'7-161,1337 . .�� �'�:,4ry ��r�Ubu'. n,�•f' •v«•
<br />12. containers 13. 14, f t
<br />11A. 11. US GOT Description (including Proper Shipping Name, Haxerd Claes, ID No T Total Unit
<br />HM Number and Packing Group) � �Quanti wtNol +
<br />G 7 (PETROLEUM NAPHTHA FILTERS )1019'34 PC -x'11 'W P
<br />N R E'001 } ERG• ,6 26) (DO19, D040)
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<br />15. Special Handling Instructions and Additional Information MI: S 7 R,/T• 10 5 0 9 i 414 /)GOO -9629-7-4 '
<br />EMERGENCY RESP 800-46e-1760( 24 I.3R. IF UNDEC,.T'TER I E 'rlrTT 6 TO GENERATOR.
<br />SK CORP AU'TH'rD TOf E St3B3EQUE14T &RnIERS• '813 0,' =, 40582, 84815
<br />1 364 S: C: 1”:
<br />SiOOT#: ?' 1
<br />1 e. GENERATo RTIFIcATi®f1; l hereby declare that the contents of this consignmentpre fully and accurately described above by the proper shipping name and are
<br />closafled, packed, marked, and labelledfplacaTddd, and aro in all respects In proper condition for transport by highway According to applicable International and national
<br />government regulations, Including applicable ,.ate regulations,
<br />1f i am Irifte quantity generator, f certify Chet i have a program in place to roo iCh min{mizas the pthe volume and taxicity of waste gsrrtereted to the degr�b i have determinedpessnt and
<br />to be
<br />economically practicable and that i have selected the, practicable method of treatment, storage, or disposal currently available to me wnrese
<br />fuh re threat to human health and the environment OR, If i am a small quantity generator, i have made a good faith effort to minimize my waste generation and select
<br />the best waste management method that is available to me and that t can'afford.
<br />Printe 1 Typed Names Signatu ` F' `,. Month Day Year
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<br />T 17. Transporter 1 Acknowledgement of Receipt of Materials Gate
<br />R r month DHy Year
<br />A Printed I Typed Name Signature
<br />a1 S. Transporter 2 Acknowledgement or, Receipt ®f Materials � Data
<br />T rinted 1 TypOd m Sig re i o DHy Year
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<br />t9. Iscrepancy Indication Space
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<br />20. Facility Owner or Operator: Certifloadon of receipt of hazardous materials covered by this manifest except as noted in item 19.
<br />1 r i Date a.
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<br />Printed I Typed Name �• t signature Monti) Clay ' Tarsi '
<br />tNhke •original Pink -TSD Feeiity Yellow -transporter Grsend9enerator's first copy
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