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SSL SK SHIP#k 231758593 <br />lllNli llliilillilNlNl�#111Nillil <br />007440102SKS <br />FrmnADDMVed. OMB No. 2050-0039 <br />Please <br />print or type. <br />UNIFORM HAZARDOUS CAT000613968 1 I -�+ 1 /iar10 <br />t. Generator ID Number 2. Page 1 of 3. R p 4. Manifest Tracking Number 74401 OL �� <br />WASTE MANIFEST <br />5. Generetors Name and Maifi Address Generator's SiteAddrass� ((if different than malls address) <br />SYSTEMS, INC. SAF LASYS T MS, INC. <br />SAFETY-KL'a' <br />PO BOX 555 5050 SALIDA BLVD <br />SALIDA CA 95368 SALIDA CA 95368 <br />209-545-1011 <br />Generators Phone: U.S. EPA to Number TX 8000081205 <br />6•Tr9W9fr yEt K SYSTEMS INC <br />7• Transporter2 Company Name U.S. EPA ID Number <br />CLEAN HARBORS ENV SVC INC - <br />8. Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS, INC- U.S. EPAID Number <br />8. <br />6000 88TH STREET <br />CA 95828 <br />SACRAMENTO + CA0000084517 <br />916-386-4913 <br />FacilityPs Phone: <br />9a. 9VU.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, l0. Containers 11. Total 12. Unit 13. Waste Codes <br />HM and Packing Group (9 any)) No. Type Quantity Wi VOI. <br />1. '. <br />O <br />F- <br />DM <br />G <br />134 <br />2. NON-RCRA HAZARDOUS WASTE, LIQUID <br />c°'n <br />( AQUEOUS PARTS WASHER SOLUTION) <br />0 <br />too wo <br />"'S PARTS, WAGI 1ER <br />4. <br />14, Special Handling instructions and Additional information TSD S SCA SAL CSS <br />24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract retained by generator confers agency,.-authori <br />1 f. <br />on initial n orte to add or substitute additional t ans o tern on enerator's_= eh <br />15. GENERATOR'SIOFFEROR'S CERTMAT10N: I hereby declare that the contents of this consignment are fully and accurately described above by the pry shipping name, and are clasAW, packaged, <br />marked and labele0placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations, 9 export shipment and I am * Primary <br />Exporter, I certify that the contents of Nis consignment conform to the terms of the attached EPA AceroWledgment of Consent. <br />I certify that the waste minimization statement Identified in 40 CFR 26227(a) (d I am a large quantity generator) or (b) (d I am a quantity geiterata) is true. <br />Geera� emes Print ypad Name Signa Month Day Year <br />lt(� (C` �1❑l <br />16. International Shipments <br />fid N U.S. ❑ U.S. Port of enbylextt <br />Transporter signature (for exports only): Date leaving U.S.: <br />tr <br />h <br />17. TransporterAcu+awl*meni of Receipt of Materials <br />T 1 Printed>r Name S Month Year <br />porter <br />�, <br />11_ <br />KL <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />i-- <br />18. Discrepancy <br />18a. Discrepancy Indication Space O..ntity nType ❑Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPAID Number <br />U <br />W <br />W <br />FacililysPhone: <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste tcoatrnerit disposal. and recycling systems) <br />0 <br />1' <br />2. H141 <br />3' <br />4. <br />20. Designated Faa'fity Owner or Operator. Certification of racetpt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrintedRyped Name Signature Month Day Year <br />EPA Form 8700-22Rev.12-17) Previous ediflons are otmiete. UE51GNAi tU PAGILII Y I EPA'S e•MANIFt51 1Y51 CM <br />T 2y 14941/156023 3}�r9AJ AJ . <br />