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R, SHIP* <br /> Please pnp[o type,(Form desigd or"use on elite(12-pitch)typewriter.) ` <br /> U OR(il) A7r4kDOUS I.Generator ID Number ` ` Form Appfoved,OMB No:2050-0039 <br /> 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> AiNIFEST ., A °m - <br /> 5 % ;Tame and MailingAddre9s SKS <br /> Generator's Site Address(if different than mailing address) <br /> (301 den Gate ��� � Golden ���� <br /> 3 5t €�t Ord Rd Atte Samuel mrhenry 18501 Stanford Rd <br /> r= CA 95377FittttSafety <br /> Generators Phone: U3 A Sam <br /> 6,Transporter 1 Company etre CA 93377016 <br /> SAFETY—KLEEN SYSTEMS INCU.S.EPA ID Number <br /> 7.Transporter2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name.and Site Address <br /> SAFETV"KLEEN OF CALIFORNIA u.S.EPA ID Number <br /> 6880 SMITH AVE® <br /> MENARK <br /> 5 10­Facilfty'sPhone: �95—440 <br /> ga, 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 4 <br /> HM and Packing Group(if any)) 10.Containers 11.Total 12.Unit <br /> 1, No. Type Quantity Wt:Nol. 13.Waste Codes <br /> W—RCRA HAZARDOUS <br /> LIDUID <br /> (USED OIL) �*� � TTUJI <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> TSWEVS Alb CBS_� <br /> CME ENL;' p#I—BIN-468-1760 ( / T I <br /> i <br /> 6th-EW S C FIC i N: ere y ec are i a he contents o tis consignment are ly arid accurate y escri aabove y ffie 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 an tional 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 EPAAcknowledgmenfof Cons t <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) i a small uantity generator)is true. <br /> Generator's/offer is PrinI d/Typed Name Signature <br /> Month Day Year <br /> O Oak <br /> � 16.Internatio aI Shipme s _ <br /> Z ❑Import t U.S. ❑❑Export from . :m'6 Port ofentry/exit: <br /> Transporter signature(for exports only): <br /> Date leaving U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials y <br /> ransporteM Pnn�ea ignature Month Day Year <br /> Q ransporte fitedfryped Name ~' /0 <br /> Signa Month Day Near <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number. <br /> fir <br /> U.S.EPA ID Number <br /> V <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> Z Month Day Year <br /> LD <br /> rOD <br /> azardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � 2. :77 <br /> it 3 3. 4esignated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 <br /> Rnnted/Typed Name Signature <br /> Month Day Year <br /> 'A Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> l <br /> 11249/156l.7 DESIGNATE k FACILITY TO GENERATOR <br />