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S5SI_ SK SHIP# 218263184 1111111111111111111111111111111111111111 <br /> 0 0 5 2 4 4 6 5 3 S K S <br /> Please print or type'(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number T X R000081 x'05 2.Pag�1 of 3�Em ggrlpy%ggse Plt g, 4.Manifest Trackin Number <br /> WASTE MANIFEST tOfO 4bt! 1 f� 0 0 5244653 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> SAFETY-KLEEN SYSTEMS, INC. SAFETY-KLEEN SYSTEMS, INC <br /> PO PDX 555 5050 SALIDA BLVD <br /> SALIDA CA 95358 <br /> Generator's Phone: 209-545-1011 SALIDA CA 95368 <br /> 6.To e U.S.EPA ID Number <br /> r �° —�� ' SYSTEMS, INC. TXRO00081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, INC. U.S.EPA ID Number <br /> 6000 88TH STREET <br /> SACRAMENTO , GA 95828 <br /> 916-386-4913 CA0000084517 <br /> Facility's Phone: <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> 1.- E LffC <br /> o { <br /> w <br /> z 2. NON-RCRA HAZARDOUS WASTE LIQUID DM G 134 <br /> (AQUEOUS PARTS WASHER SOLUTION) <br /> 3. ( C� <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:SCA SAL CSG: <br /> 24 HR EMERGENCY #1-81210-468-1760 (SK I TFI) <br /> AUTH AS "AGENT-FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <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 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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> =os/Offeror's Pri yped Name Signature Mo Day Year <br /> —J 16.Interna' nal hipments <br /> F— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> Tr spo er 1 PrintedlTyped a Signature Mo Day Year <br /> fL ^^ ^ �� <br /> coco VIA <br /> 1 <br /> QTr nsportef 2 Pri /Typed Name Signature Month Day Year <br /> c <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quantity El Type El Residue El Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> C3 <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> ti19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. ��R� 2. H14j, <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest exo as noted 04m 18a <br /> P y ed Name Signa ` Month Day Year <br /> EP r 7 2 P[eYi u y}I n rPc4b olei@. DESIG TED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> Y <br />