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SSL SHIM 220676337 <br /> Please print or type,(Form designed#or Use on elite(127pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator.ID Number 2.Pa 1 of 3. Se h 14.Manifest Trackin 'Number <br /> UN§Fr M HAZARDOUS 9 � Pg <br /> ASTE MANIFEST �.$�• C �f SKS' <br /> 1 005728.72 <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Gene'rator's Phone': <br /> 6.T 1Pq1�FmrRL . ._ ySTE � � U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site AddressWETY—KLEEN OF CALIFURNIA9 . U.S.EPA ID Number <br /> 6880, SKIS'.l AVE. <br /> NEWRK CA 94560 <br /> CAD980807.41a <br /> ;Facility's Phone: <br /> ga 9b.U.S.DOT Description(includingProper Shipping <br /> Name,Hazard Class,ID Number, 10.Containers 11.Total V;Unit <br /> HM and Packing Group(if any)) No Type Quantity WIL/VQ• I Waste Codes <br /> 1.o ( OIC.) � �LIGI ID � � <br /> z 2. <br /> W . <br /> C9 <br /> 3. <br /> 4: <br /> 14.Special Handling Instructions and Additional Information24 C ff <br /> t <br /> R EMERGENCY 1.-800-468-1760 (SK `AFI B <br /> UT "AGENT-FOR" BY GEN TO RETAIN L1C S $ CARRIERS CESSARV <br /> 15: GENERATOR'S/OFFEROR'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 labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If ezportshipment and i am the Primary <br /> Exporter,l certify that 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 quantity generator)or(b)(1/6 a small quantity generator)is true: <br /> Gdnerator's/Offerors PdntedfTyped Name Signature Month Day Year <br /> Z. Al"9454 <br /> Li 16.Inteftional Shipilhents <br /> t- ❑Import tdU..S. ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only); Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> E2, ransporter 1 Printed/Tymd Name ignature Month Day Year <br /> nom' <br /> M' Transporllrft PrintedfTyped Name gignaturi Month pay Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ' <br /> ❑ Quantity El Type ❑Residue ❑Partial Rejection'. ❑Full Rejection " <br /> Manifest Reference Number: <br /> 18b.Aitemate Facility For Generator) U.S.EPA ID Number <br /> V •. <br /> ua- Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month' Day Year <br /> a <br /> N19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste Ueatmem;disposal,antl recycling systems) : <br /> G 3'1 (1 2• 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' _ Month Day Year <br /> °, r'.1 :•.:, (.�� �. �"� � �� - -�_ � �`� f�` <br /> EP 8 eu. Previous editions are obsolete: DESIGNATED FACILITYTO GENERATOR' <br />