Laserfiche WebLink
SSL SK SHIP# 23041830 <br />Please print or tvoe <br />VINIII A II VIIINnNI NIIII I III III <br />rr/1rlAnIOfVV-«t V rzrir/ rfewuuseumonsareoosgigte. DESIGNATED FACILITY TO EPA'se•MANIFESTSYSTEM <br />UNIFORM HAZARDOUS <br />1. Generator ID Number , _ C <br />T d fY'k�t7lin�t(;1' 0 <br />2. Page 1 of <br />1 <br />3.E m R s se Pho <br />�+�� 1% �I <br />�NM�VVGV. VIYIJ ,Y V. GV JV-UVJJ <br />anifest Tracking Number <br />WASTE MANIFEST <br />! T7607276483 <br />SKS <br />5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />SAFETY-KLEEN SYSTEMS, ItdC. SAFETY-KLEEN SYSTEMS, INC. <br />PO BOX 555 5+50 SALIDA BLVD <br />SALIDA CA 95368 <br />Generators Phone: 209-545-1011 SAL IDA CA 95368 <br />6. T',4 ffl t o iiVft SYSTEMS INC U.S. EPA ID Number <br />TX Rt71O0tZt81 r^_B1S <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />CLEAN HARBORS ENV SVC INC. MAD039322050 <br />8. Designated Facility Name and Site Address SAFETY--KLEEN SYSTEMS, INC. U.S. EPA ID Number <br />f,000 88TH STREET <br />SACRAMENTO , CA 95B28CA0000084517 <br />916-386--491.s <br />Facility's Phone: <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers <br />11. Total 12. Unit <br />HM <br />and Packing Group (if any)) No. Type <br />Quantity WtNol. 13. Waste Codes <br />W <br />„Z, <br />2. NON—RCRA HAZARDOUS WASTE t_I�UID DM <br />G 134 <br />FaO�_ti T I�1N) <br />(AC!UEI01je, MARTS: WASHER3. <br />rr <br />4. <br />14. Special Handling Instructions and Additional Information TSD a SCA SAL_ CSG: <br />E4H EMERCENCYI1800--468-1767,-CH/S){,'TFT-Con r•act retairwd by generator confers agency ar_rthori <br />or initial trap= orter to add orsubstitute additional trans arters on enerator's behalf. <br />15. GENERATOR'S/OFFEROR'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 EPAAcknoMedgrAnt of Consent <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity general orb (if I am a pmyll quantitj generator) is true. <br />Gene r r r rs Printed/TypedNam Signatu Month Day Year <br />16. International Shipments <br />[Iimportto U.S. ❑Export from .S. Port of entry/exit: <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />Uj <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transpo r 1 Pri hyped Name Signature <br />lb <br />Month Day Year <br />a <br />0- <br />r <br />l <br />z <br />Transporter 2 Print yped Name Signal a Month Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity❑ ❑ ❑ Full Rejection <br />El Residue Partial Rejection / <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />tai <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />Q <br />1 <br />2. H 1 lF 1 <br />3' <br />4. <br />-.. <br />20. Designated Fadlitywn <br />Oer or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printedlryped Name Signature Month Day Year <br />rr/1rlAnIOfVV-«t V rzrir/ rfewuuseumonsareoosgigte. DESIGNATED FACILITY TO EPA'se•MANIFESTSYSTEM <br />