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Generator's Phone: ' W a " L W i AtI I 6 , TWAlpr$teeC�t O—RMR SYSTEMS INC U.S. EPA ID Number TXR00$081505 7, Transporter 12 Company Name U.S. EPA ID Number CLEAN HARBORS ENVIRONMENTAL SVC INC . MAD039328250 8. Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS ,('EMS , INCv U.S , EPA ID Number 6000 88TH STREET SACRAMENTO CA 9588 916--386-4913 CA0000084517 Fadlity's Phone : 9a 9b, U .S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 , Total 12, Unit 13, Waste Codes HM and Packing Group (if any)) No. Type Quantity Wl.Noi. 1 . O z 2. NON--RCRR HAZARDOUS WASTE LIQUID DM !! G 134 LU ( AQUEOUS PARTS WASHER SOLUTION ) 3 . NON— RCRA HAZARDOUS WASTE LIQUID DF G 134 ( AQUEOUS PARTS WASHER SOLUTION ) � 0 +17 4. 14. Special Handling Instructions and Additional Information Tray. D Y SCA SAL CSSG 24H EMERGENCY#800-468- 1760-CH / SK / TEI - Contract retained by generator confers aggency authori y on initial trans orter to add or substitute additional transporters angenerator ' s behalf . 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, marked and labelediplacarded , 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b)AI am a small quantity generator) is true. Gen rsfOfferor' ' , ntecirlyped Name Signature Month Day Year VIi 16. Intern 'on Shipments F— ❑ import to U.S. Export from U.S . f entry/exib Transporter s nature (for exports only): a leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials lrC Tra iter 1 Printedlf ; Name Signature Month Day Year. O !!#t (111 1 .1 v°i Month Da Year z Transporie Pd edTyped Name Signature y 18. Discrepancy 18a, Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number LL Facility's Phone: CS 18c. Signature of Alternate Facility (or Generator) Month Day Year 4 z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) UJ . 1 . -fart R 2 H141 3' H141 4. ki20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a tPrintedfTyped .blame . Signature Month Day Year 7-I � �� + + ° Si �aae 3 ) 14�34i / 15fi0E3 DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM