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Please pant or e �Aim designed for use ort elite(12-pitch)typewriter.) Form Approved,OMB No.2050.0039 <br /> ..Generator ID Numper ' 2.Pagel of 3. h 4.Manifest Tracktn Number <br /> UNIF RDO's SKS <br /> I#NIF115s"T ' C� } <br /> be algr s Game and Ma ling Address <br /> Generators Site Address(if different than making address) <br /> GenosPhe` <br /> U.S.EPA ID Number, <br /> s.T r r�4+�,jkU&-_ e SYSTEM T k a <br /> U.S.EPA ID Number <br /> 7.Transportgr 2 Company Name <br /> U.S.EPA ID Number <br /> B Designated Facility Name and Site Address' SAFETY—KLEEN g ,y��75�#Vg�� _ <br /> NES#ARK � CA 9455 <br /> 510-795-4400 <br /> Facility s Rhone: <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waite Codes ' <br /> 9a. No. Type Quantity Wt.Nol. <br /> HM and Packing Group(if any)) <br /> (ABED TLS 0 . <br /> ga <br /> Z 2• <br /> 3:' <br /> 4. <br /> 14.Special Handling Instructions and Additional Information r ffi <br /> 4 FSREMERGENCY 01-800-468-1760 60 ( ! I I <br /> A THA "ROENT—FOP Y EN TO RETAIN LICENSED U CARRIERS A tE ARY <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classlfied,packaged, <br /> marked and labeledlplacardad,and are in all respects in proper condition for transport according to applicable intemabonal and national governmental regulations:If expod shipment and f am the Primary <br /> Exporter,I certify the contents of this consignment conform to the terms of the attached EPAAcknowledgment.of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantitygenerator)or(b)(if I am a s al quanlity,generator)is true. Month Day Year <br /> Generator'slOfferoes Printedfryped Name Signature <br /> 16.Intemational'Shipments- �Import to U.S,,,. �Export from U.S. . Port ofentry/exit: <br /> Z r Date.leaving U.S.: <br /> Transporter signature(for exports only): <br /> L4d <br /> W 17.TransporterAcknowledgment of Receipt of Materials Month Day" Year <br /> Tra spo ter 1 PrintedfT d Name Si lure <br /> a ��/� l l if Month Day Year <br /> Q Transpo 2 Printed/Typed Name <br /> Signature <br /> 18.Discrepancy # <br /> 18a.Discrepancy Indication Space Quantity r ❑Type 0 Residue 0 Partial Rejection <br /> Full Rejection <br /> E , <br /> Manifest Reference Number: ^ <br /> 18b.Alternate Facility(or Generator) <br /> U.S.EPA ID Number i <br /> RFaciliyys Phone: Month Day; Year <br /> W 18c.Sig <br /> nature of Alternate Facility(or Generator) <br /> d <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Q, 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardouamatedals covered by the manifest except as noted i tem 18e <br /> Signature Month Day. Year <br /> Printedfiyd game , <br /> EP o 87 9.2 .Iev. 5� Previ editions ate o olete. ,� DESIGNATED FACILITY TO GEN BATOR <br />