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<br />DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM
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<br />UNIFORM HAZARDO6�o �—PTg,2 — f 3 n4 e Phone 4
<br />y p It Res Response . Manifest Tracking Number
<br />Yf� 11 —41111-1760
<br />WASTE MANIFEST
<br />--011 —11d
<br />006959619
<br />S KS
<br />5 C"erall-T FTI 1.1alino AdNessC-ene,'It,,es Site Aurfiess (ifdifferent than mailing ardrcss)
<br />SAFF-TY—KI-F-F-J-4 SYSTFWS, RIC i3AFFIY--KLEEN
<br />SYSTEMSINC.
<br />PO BOX 5-jS ,
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<br />U S Ept, 0 Number
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<br />T Comon,ly Name
<br />US EPA ID NumberPLEPN
<br />HAPBORS F -NV f POINIMIIF INIT-i-20 �M'
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<br />8. De. 7gn—m,ed —Nam
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<br />6000' ("I'UH STP'EFT
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<br />CA0000084517
<br />Faulity's Phone.
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<br />96 U S GOT N,m Hazald D Nlumlbe-
<br />10, Containers
<br />11. Total
<br />12. Unit
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<br />Quantity
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<br />11 Waste Codes
<br />No,
<br />Type.
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<br />14
<br />14. Special Handling InSITLIC[ions and Addi"hnal Information
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<br />15 GENERATOR'SICIFFEROR'S CERTIFICATION: I herchy dec!nre that thr. o-ofent, ?f!n,s rnmgnment are fully and accurately described ab,,we
<br />by the rrcpEf shipping name,
<br />and are classified packaged,
<br />marked and labe.led'!Pia,,a;cried and u.,e'n aij respl,csin proper condition for iran>p)n ztUxrding to a.ppiicabte internalonaland mpjona! govern.rertal
<br />fegulations. If export shipment
<br />and I am the Primary
<br />Ex , ceder, I certify that th,,, cenlepi�, of fh;s consignment conform to the terms of the,!tadhed EPAAckn%ledgirtent of Consent
<br />I certify that the waste wiln-malion statementidentifiedin 40 CFV R 262 27(a) (it' 2m a large quantity generator) of hn} (if .. e Small quanbly generator)
<br />is true,
<br />Gef)xator'srCr,aro' PrintedfT,;f, N.!re ,Tqn
<br />Month Day Year
<br />,
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<br />16. international Shipments
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<br />Import to U.S Ex,crd Km Port, of eniry,exn
<br />Tfansporter signature (forexportson;Y) U.S :
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<br />17. Transl)orLerAcknovv4Ldgri,�k.�nt of Rerei;)i ofklatenqfs
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<br />Tr ;Purh?r I Print-diTyped Name — Itu/
<br />Month Day Year
<br />0
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<br />Transporter 2 Printed/Typed NameSinnatuic
<br />11
<br />Month Day Year
<br />9
<br />11-11"
<br />18 Discrepancy
<br />18a. Discrepancy Indication Space Quantity Type ❑Residue
<br />❑Par!4 Rejection
<br />El F01 Rejection
<br />Manifest Reference Number
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<br />le-
<br />181h. Alternate Facility (o! Generator)
<br />U.S. EPA ID Number
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<br />Facility's Phone:
<br />wFacility
<br />Signature of Alternate for Generator)
<br />Month Day Year
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<br />19. Hazardous Waste Repot, Management Method Cedes fife-, codes fcr hazardous w?,qle treatment disposal, and recycling systems)
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<br />3
<br />20 Designated Facility Owner or Operator Cerlifi,ation of receipt of hazirdcus ma( ena-Is cc% cIeri by the manifesi evept as ni:Xed in Item 18a
<br />Pruiled/Typed Name signature
<br />Month Day Year
<br />n,
<br />DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM
<br />
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