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Please print or type. (Form designed f sWif i elite (12 -pitch) typewriter.) Form Approved.' Oft No. 2050.0039 <br />1^Generator ID Number 2. Page 1 of 3. Emergency Response Phone 14. Ma a Tr ki um er _ J <br />uNIFaRM HAzaRabu3 CAL00032 2 SS 1-800-468-1760 <br />. 800-468 -1 60 K <br />WASTE MANIFEST <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />fid'°" PRODUCTION SERVICES COP PRODUCUON SERVICES <br />1905 N BROADWAY PO BOX 5189 1755 N DROADWAY ST <br />:mI'l30fdTt3t CA 9520S PO Box Etas <br />Generator's Phone: 209•N547-�i 600 STOCKTON CA 95205, <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />SAFETY -KI EEE SYSTEMS, INC. T R0 0050 NIC) <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address AFFTY" KLEEN SYSTM1 INC, U.S. EPA ID Number <br />6000 8TH STREET <br />SACRAMENTO CA 95828 <br />916-386-4913t.A0 k0G�0% �3 H1 <br />Facility's Phone: <br />9a: ^ 9b. 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)) No. Type Quantity Wt.Nol. <br />ce- x 1. WASTE PAT.NT RELATED MATERIAL, 3, 'UN12d'3, D11 P F"003 D001 D018 <br />1 i <br />D039 212 <br />L <br />f <br />3. <br />i <br />4. <br />14. Special Handling Instructions and Additional Information S %41P#?`'67yi 50373S64 369976 ?"Y1,01.5 C66: 24 <br />24 HR E.MER ENCY (AF ET°>1"-KLEEN 94138), <br />4' 1 <br />15. GENERATOR SIOFFEROR'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, <br />marked and latieledlplacarded,and. are in all respects In proper condition for transport according to applicable international and national governmental 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 Consent. <br />I certify, that the.waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) oqag4m a small q ntity generator) is true. P <br />Generator's/Offeroes Printed/Typed Name "Signatu Month Day Year <br />J 16. International Shipments s; <br />Import to U.S, 0 Export from t1.. P dleaving <br />rylexit <br />Transporter signafu�e,(for`exports only). ' 4 U.S.: <br />U, 17. Transporter Acknowledgment of,Receipt of Materials ;. 4 <br />Transporter 1 Printed/Typed Name Signature Month Day ; Year, <br />1 <br />QTransporter 2 PrintedlTyped Name Signature Month Day Year <br />18. Discrepancy <br />...._ . <br />18a: DiscrapanGytndk;ation Space -_ .. _.. i. - - .�-.r-�l �} �{ <br />0 Quantity ❑Type L�J Residue LJ Partial Rejection LJ Full Refection <br />r <br />// nifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />Q{�'� f •sr g {� <br />ri Facility's Phone: t i <br />W 78c—Signaturer-Gene <br />:Signature of Alternate Facility (orator) Month ,; Day Year ' <br />4 ' . <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recyclingsystems) v <br />2. 3.. 4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manffestexcept oted in Item 18a <br />Pr i Y [Typed Name Signature Month Da <br />EPA 22(Re-V 05 Previous to sareobsoete: DESIGNATED FACILIT GENERAT R <br />