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t_ ; ! SK SHJPif i P. 591 . 171 ? IIIIIIIII � IIIIIII�IIIIIIII �IIIIII � II) 0 0 6 4 6 2 4 9 6 S K S Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page of 3. Emer ency Response Phone 4. Manffeet Tracking Number WASTE MANIFEST T X Roll�tn0e 1 h � (�thf7l b 006462496 SKS 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) SAFETY — KLEFN SYSTEMS , TNG , SAFETY — KLEEN SYSTEMS , ThIC , PO PIOX 55 505171 SAI . TAA BLVD SAL 3 Dct CA 753768 Generators Phone: 209 -545 - 1011 SAL I DA 6. Trans der 1 Com ny Name U.S. EPA ID Number j Sf�FFT 'Y - ! FEN SYSTEMS INC TXR000001. 2095 7 , Transporter 2 Company Name U.S. EPA ID Number r, I _ EAN HARBORS ENVIRONMENTAL SVC INCe MAD039322250 8 . Designated Facility Name and Site Address THERMO FLUIDS INC U.S. EPA ID Number 1. 2533 SF CARPI: NTE DR Ct . ACKAI4AS , CIR 97Q115—• 8 � lFtft 5171 ? � 7P )1 -- 4F-, iF, 0PG! 1710 !/I � 1 ; 197 Faclli 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 Wtivol. 1 NON - RCP, A HAZARDOUS WASTF SOLID � F' P23 of ( DRATNfF." WUNDRAINFD USED VIII_ FII _ TFRS ) a L LU 2 . W 3. 4 . 14, Special Handling Instructions and Additional Information TSD ' TPO RAL ;?4 HR EMERGENCY # 1 — !3001 468- 1760 ( CH / SK i TFT ) FH Afi " . f. ! — Ff1R " ply r1 Tn RETAIN IF ' FNEIF I B, ' T 4 f' r' c' P 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 labeled/placarded, 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 EPA Acknowledgment of Consent. I certifythat the waste minimization statement Identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (iflfiml small quantityenerator) is true. n alor'sl Bero rinled(lypedName � Signature ih 01 ay 1Ygar /7 —r 16. In matin al Shipments F ❑ Import to U.S. =Port from U.S. rt of a Wexit: Transporter signature (for exports only): Da •tg U.S.: 17. Transporter Acknowledgment of Receipt of Materials ;FFinpoder 1 Print ped Name natyr6 / Mo th Davy Year Transpri inted, 99.1ame Signature Month Day Year .� «.5� � 3 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ ResidueEl j j Partial Rejection Full Re ecticn Manifest Reference Number: 18b. Ntemate Facility (or Generator) U .S. EPA ID Number J U LL Facilitys Phone: w 18e. Signature of Ntemate Facility (or Generator) f.lonth Day Year a z N19. Hazardous Waste Report Management Method Codes (Le', codes for hazardous waste treatment, disposal, and recycling systems) � 1 . � 2. 3. 4, 20, Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest ex ed in Item 18a nn yped Name ure Month Day Year 'ah a ! L M .... nEPA Form 8700-22 (Rev. -05) reviousediion re obsolete. DES GNATED FACILITY TO DESTINATION STATE ( IF REQUIRED)