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u. ya SSL. SK SHIP# 22UR9524? <br /> <_ <br /> Please rintoc e.(Form designed foruse on elite (12-pitch pewriter Form Approved. OMB No. 2050-0039 <br /> U JiFO RDOUS 1 GeneraItortD Number CAL 0002,9941 �4 2. P ge of 3. rns� $ � °NSA 4. Manifest rackinNbar SKS SWASTE MIFE$7 ( U 3J 3 4 <br /> 5. . arorrs N ` e d Mailing Address rater's Site Address (If different than mailing address) <br /> ctwso <br /> 1001 toke5 dive <br /> STOCKTON Cts 9.521 5-4023 <br /> Generators Phone: h <br /> 6. Tr <br /> SAF <br /> "140°'P;CP9 SYSTEM ` INC U.S. EPA <br /> 7 Ti�1. NV `IRONMENTAL. SVC INC. U.S. EPA ID Number MAD039322250 <br /> 111 8. Designated Facility Name and $Re Address CLEAN HANDURS ENV I RONMENTAL SERV UL51 IN U.S. EPA ID Number <br /> 2247 S HIGHWAY 71 <br /> 308-235- 4022 KIMBALL. , NE 69145 <br /> NED98172351 : <br /> Facilil es Phone: <br /> ga. l9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit <br /> and Padtin Group if an 13. Waste Codes <br /> HM - 9 PC Y)) No. Type Quantity WOVoI. <br /> ' 1 We Dot& <br /> IDS <br /> N. a. 5. ; , �G Ill <br /> ' 0 <br /> jj <br /> 2. . <br /> 10 <br /> 3. <br /> C <br /> 14. Special Handling Instrudiohs and Additional Information p <br /> 1..) ERG# 128 ` 0 L "th <br /> H EMEROtNCY#800Q 468- 1760-&CHJSK / TFI�-Contract retained by generator <br /> � confers _ agency authpri Y <br /> on : _initial transporter to add or substitute additional transporters ongenerator ' s behalf . <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: t hereby dedare that the contents of this'consignment are fully and accurately described above by the proper shipping name, and are classified, packaged; <br /> 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 <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAdmowledgment of Cqnsent. <br /> Icertify that the waste minimization statement Identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if l Im a small quantity gen tor) Is true. { j <br /> Generatoesf0(fare+ PrintefypeclName Signa ure M th D Y/ea <br /> t .J <br /> r 16: International Shipments ` vl <br /> ❑ Import to U.S. EJExpo4,t91h U.S. Port ritzyle>at: <br /> Transporter signature (forexports only): '' it, I -� Dat . saving U.S.; <br /> 17. TrdnsporterAdmowledgment of.Receipt ofMatedals , <br /> Trarip <br /> er Printed7Typed N Signature Month " Day . Year <br /> i 0 r!� Z- <br /> dz Transpo me yped Name r Signature Month Day Year <br /> Ole <br /> 18. Discrepancy <br /> IL <br /> 180. Discrepancy Indication Space Q Quantity ❑ Type Residue El Partial Rejection O Full Rejection <br /> Manifest Reference Number: <br /> 18ti. Alternate Facility (or Generator) . U.S. EPA ID Number, <br /> U <br /> LL Facility's Phone: <br /> 18c, Signature ofAltemate Facility, (or Generator) Month Day Year <br /> d _ .0VA <br /> m <br /> 19, HizardDus Waste Report Management Method Codes (lie:, codes for hazardous waste treatment, disposal, and recycling.systems) <br /> LU t . 2. . 3. 4. <br /> 20. Designated Facility vneror Operator: Certification of receipt ihazardous materials covered by the manifest e ' pt as noted in Item 18a <br /> Pdnted7Typed NameSigna Ye <br /> E Pj F)° ev11. use itionsareobsolete. . r� IG ATED FA TO . GENERATOR STATE (IF REQUIRED) , <br /> ` <br />