Laserfiche WebLink
KA- SK S'HIP4 <br />Please orint or Wee <br />RiwiiiuuiwmiiiiAuiNixui�i <br />0 0 7 1 8 1 3 7 5 S K 8 <br />, . A nkAp Kl� 9nr;n-f)n'AC1 <br />EPA Form 8700-22 Rev. l�-!r) trPv1uy <br />UNIFORM HAZARDOUS <br />WASTE MANIFESTA <br />Generator ID Number <br />0 0 113 t-3 1.3, 9 el B <br />2. Page j <br />I I <br />1. fnegg _ 4 'N t" <br />liX.FJ1. �_P LA <br />!� _ <br />4. Manifest Tracking Number <br />SKS <br />5 Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />S(IFETY-KLEEN SYSTEMS, I MC, 'AFETY-KLEEN <br />0 , -, <br />YSTEMSI N( <br />P 0 B OX j 5050 SALIDA P� 1. V11) <br />TDIA 95"' <br />iAt Gh <br />Generator's Phone: SAL IDA <br />1. Tr'? � am� US EPA —IDN <br />K'ptt� umber <br />rt'f i <br />ot� SYSTEM, iNt. -,q <br />, TX 130 0 0 i 8 1 ;,:-1 0- <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />CLEAN HqRBOR9 ENV SVC INC. MA003932225vi <br />T—D,7,,gnat,d Facility N d Sit. AddressU.S. EPA ID Number <br />SAFETY-I'LEEN SYSTFVJ'�', INC. <br />6000 8BY11 STREET <br />`ACRAMFNTO CA 9582S <br />Facility's Phone: <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10.Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HA -1 <br />and Packing Group (if any)) <br />Quantity <br />Wt Not. <br />n <br />0 <br />ul <br />NO{ RI ljnZA1-ZD0l-IS 71 -11 D <br />f <br />G <br />1-14 <br />(AQUEOLIC PARTI-3 W A E'H P 6 <br />�-4 �-,- <br />4. <br />14, Special Handling Instructions and Additional Information <br />C G <br />r-etainq en e t -a' I -or- r�vnfpr� 0t,1 <br />24H -e d by <br />On initial tr,ansparter to zicid or substitute --qdditil 0 rial tl-an-'�Jgrt el= npl,) ny,'; hehilf� <br />15, GENERATOR'SJOFFEROR'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 labeledtplacarded, 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 aOa I quantity generator) is true. <br />GeNlors/Offeries Pdntedl;yped Name Si ai Month Day Year <br />cv� <br />110 <br />16, International Shipments❑ <br />1:1 Import to U.S-U.S. Port of entrylexit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter AcknoMedgment of Receipt of Materials <br />Tporter 1 Printed/Typed Month Day Year <br />L-A.-,L-A.-,OL T I ok'� Z7, : I 01-�' I cl� 1 19 <br />C <br />i <br />Transporter 2 PrintedfTyped Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rjeati., Flull Rejection <br />Manifest Reference Number: <br />18b. Altemat - e - Facility (or Generator) U.S, EPA ID Number <br />Facility's Phone: <br />Month Day Year <br />­Faafi� <br />W18c. <br />Signature of Altemate (or Generator) <br />Z <br />19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />UJ <br />1. 2. 3. 4. <br />jil-211 1-1 H141 <br />7e, 1 <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />year <br />Signature Month Day <br />PrintedrTyped Name <br />nr-4Zlr.1UATr-n PArIl ITY Tn FPA'q P -MANIFEST SYSTEM <br />EPA Form 8700-22 Rev. l�-!r) trPv1uy <br />