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SK SNIP# 221936344 ���I��'�'�'�) <br /> 1 �I�I <br /> P se print or type,(Form designed for use on elite(12-pitch)typewrites) <br /> 0059472168 K8 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2:Peg 1 of 3. m R se eeh 4.Manifest Tracking Numberoved.OMB No.205( <br /> WASTE MANIFEST )"0 '4 1!t�€t <br /> 5.Generators Name and Mallin Address 005947216 S K% <br /> t^�} ;¢ — �;F�1,d e Gfat e eAddress CCIf different than mailing address) <br /> ADESA V. <br /> A':aPEI W = :,Stanford Rd Attn Samuel Mchenry 18501 Stanford Rd <br /> 6RAt"Y CA 95377 Attn Safety Sam <br /> Generator's Phone.. 209--1339 934 _ <br /> 6.T .-.y o n Tf SYSTEMS INC TRACY U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and She Address <br /> SAFETY—KL.EEN OF t A)-I f f RN I A U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> _ NEWARK CA 94560 <br /> Faclli es Phone: w,P D9 8 0,B 8;4 18 <br /> go. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> M HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity WtJVoI. <br /> 1• N,I€N--13CRA HAZARDOUS WASTE L.IQUII) <br /> o xt?i a' CIL.) ' 001 TT <br /> r Uj 2 <br /> D C7 <br /> n - <br /> 3• _ <br /> 0 <br /> 14.Special Handling Instructions and Additional Information <br /> TSD .EVC I"tl7 t f. 8 ( y?ty R <br /> i Vit' I*R'55 EMERTG�3{{a--��,",•{CY ��1,..t�0�ff'iC'^'.lfi�18--3.710 (sr7'tKp�/r T��^'I)� c SUB <br /> [+/�pp�c�7� (� /� `-�yF/ <br /> Ai't�" t'is'�i n`�•t�'rr.=NT--FOR" 8i GEi`i T RETAIN ILr4tYSED SUB CARRIERS 1"iS NECESSARY <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: 1 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)orb O am a smalluanti <br /> (dl <br /> Generators/Offemes Printed/Typed Name quantity generator)Is true. <br /> Signature <br /> i t�r C S Month Day Year <br /> F 16.international Shipments 1016 .Q <br /> ❑Import to U.S. ❑Export from U,S. <br /> Z Transporter signature(for exports only): Port ofentry/exit:Date leaving U.S.: <br /> W 17.TransporterAdknowledgment of Receipt of Materials <br /> 1X nTrter 1 Printed e <br /> a ` nature Month Day Year <br /> ransporter Printed/Type Name Signature �� A <br /> Month Day Year <br /> 18.Discrepancy <br /> t <br /> 18a.Discrepancy Indication Space D quantity [--jType ❑Residue ❑Partial Rejection ❑Full Reje*'nq' <br /> e; <br /> 18b.Alternate Facility(or Generator) Manifest Rate re Number: <br /> U.S.EPA ID Number <br /> V <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> ZMonth Day Year <br /> N19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1 2. 3. 4, <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br /> Printed/Typed Name - Signature <br /> Month Day YeaB'�� <br /> EPA 1`0 $7 Q 22 R8 Previous editions are obsolete. <br /> t a'9'. z, a. , i / i; / OGCIrrdATC11 I=A^11 IT..,., -- — -- .. <br />