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E <br />-M2 <br />Pie ace nrint— hipri Ir -'mm dAQinnArI fnr ima nn ARA 1119-iiitc.111 Wnp-writer I <br />�Illhlll ISI <br />ISI <br />S No. 2M -W39 <br />ETAF <br />�FVA Previous editions are obsolete. <br />POO I. <br />DESIGNATED FACILITY 7-0 DE51-INATION5 FAX (W KItQUIKItU) <br />1. Generator 10 Number <br />UNIFORMHAZ�ARDOU <br />UNIFORM HAZARDOUS Cf 11)9,32,343P,93 <br />'PTr0cy4"6F8!Q1'W@ <br />� <br />11 MO C Number <br />'9 <br />.002 43641 SKS <br />M <br />WASTE <br />W�ASTEMANIFEST <br />MANIFEST <br />5, Generators Name arid Mailing Address Generators Site Address (ildifferenithan malding address) <br />5110 PACIFIC AVENUE BOX STORE <br />STOCKTON cn 9.5207 <br />Gwe;falors Phone: <br />6, Trans otter 1Coin n Name U.S. EPA ID Number <br />C,rY--K ENn SYSI-EMS, INC� <br />7,Transpottt,r 2 Company Name U.S. EPA 10 Number <br />A b I IZA M8 P <br />--FRI <br />8, Designated Faciii(y Narne andoileAddIfess SAITTY—KLEEN SYSTEMB INC. U.ffiftlD Number <br />i <br />1722 COOPER CREEK ROAD <br />DENTON, TX 76208 <br />940-483--5200 T0077603371 <br />±ai ria r's Phone: <br />9a <br />go. U.S, DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. C..fj!!Li;d <br />11. Val <br />12. Unit <br />13. W.I. Codes <br />NO. <br />and PacIdliq Group (if any)) <br />Quantity <br />WWI <br />X <br />1, <br />15ASOLINE <br />nil <br />P <br />343 <br />OUTS <br />0 <br />3 UN1203 P6 11 (RCRA EXEMPT) <br />0 <br />2. <br />ILJ <br />3. <br />..... .. ... <br />4. <br />774SpLclal Handling Instructions and Additional Information SK Q IP#204504054 5 51R952 1986801 <br />I)ERB#128- <br />IP CONTRACT #94138) <br />2-4 F1R EM .11GENCY #I -a00-468-176101 '19 AFETY-10- <br />K AIJTIV D TO Uffi FENT CA R -EM" 81681,827,U-, B5 <br />S SIM"II R <br />I <br />. <br />15- GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and murately dewbed atlove by the proper shipping name, aid are classified, packaged, <br />marked and labeled,iplacaafed, and are in at[ respects In proper condition for transport according to applicable international and national gmmmwft 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 EPAA*rwMedgwt of Consent. . <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quentily generator) or (b) (01 am a small quart p genet two, <br />Ge er r s/ON 'S Printed/Typed Nae <br />) Signe ree Month Day Year <br />—j <br />1— <br />I Inlerflatiomishipinerlis <br />0 Import to U.S, ❑ Export from U.S. Poo of an t <br />= <br />I Transporlef signature (for exports only): Date lea ' U.S.: <br />17, Trans pixter Acknowledgment of Receipt of Materials <br />0 <br />Tfansp 1 1 Printecifty d Nome 4pa sr Month OV Year <br />a_ <br />Transpo.ler 2 Ptinled/Typed Nome Signature Month 0 year <br />/11, 4117 <br />Ill. Discrepancy <br />18a. Discrepancy Indication Space El El Type. El Ricisid. n P.,UW R.O. El Full Rowi.. <br />Manifest Reference Number. <br />18b, AlternWa Facility (or Generator) U.S. EPA 9) Number <br />Facility's Pl',.one: <br />w18c. <br />Signature of Alternate Facility (or Generator) <br />Month Day oat <br />19, Hazardous Vyaste Report Management Method Codes (i.e., codes for hazardous virile Ifeaknent disposal, and recong systems) <br />LLJ <br />1 <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Codification of receipt of hazardous materials covered by them I except as noted in fleet 18a <br />— LV, <br />Ptibjwyped Name ay Tr <br />I <br />ETAF <br />�FVA Previous editions are obsolete. <br />POO I. <br />DESIGNATED FACILITY 7-0 DE51-INATION5 FAX (W KItQUIKItU) <br />