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SSL. HIP# 226241143: <br /> Please print or type. I Form Approved.OMB No.2050 0039 <br /> owF6RM HAZARDOUS 1:Generator Ib umber 2.Page of 3. me Re e P - 14. m s rackin Number` SKS CRLG�G346675 ' �. �.-� -���� �� <br /> W TE MANIFEST z <br /> 5.G erators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> ADESA Golden Sate ADESA — Golden Gate <br /> 16501 West- 'nford Rd Attn Samuel Mchenry 16501 Stanford Rd <br /> TRACY , GA 95377 Attn Lester Saba <br /> Generators Phone: 614-5374 TRACY , ' ' CA 95377-97 <br /> / 6:Tr m y e� U.S.EPA ID Number' - SYSTEMS IN i TXROOOO81205 <br /> 7.Transporter 2 Company Name , U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY-KI-ttN OF CALIFORNIA U.S.EPA ID Number <br /> 660 SMITH AVE. <br /> NEWARK , CA 94560 <br /> 510-795-44 CAD980887418 <br /> Facillys Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1: NON R RA HAZARDOUS WASTE LIQUID G 221 <br /> o BUSED OIL) ' 1 <br /> UJ <br /> 2. <br /> 5 <br /> S tsf <br /> 3: <br /> 4. <br /> , Yr' <br /> 14.Special H ndling Instructions and Additional Information TSI)m EVC 797691 1 AD20198 CSCE e <br /> a 24H EMER NCY 600-458-1760-CH/SK/TFI--ContraIct r4ained by go»erator confers ae»cY autllori Y <br /> an initial trans ort r o add or substitute ddi transportersgenerator's <br /> 1,'15. GENERATOR'SIOFFEROR'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 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 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 if I am a sma ' ' generator)is true. <br /> Generatoes=erors Printed/Type Name Sly Month Day Year. <br /> SAM <br /> 16.Inter ational Shipments <br /> E ❑ImpLor <br /> ort to U.S. Y,❑Export from U.S. Port of entrylexit <br /> ? Transporter signature(for exports only): Date leaving U.S.. <br /> W 17.Transporter Acknowledgment of Receipt of Materials r <br /> 1ETru sported Printe ITy d Name - Si re i Month Day Year <br /> i 1 <br /> Z Transp6Ker 2 Printedffyped Name Signature..J Month Day Year <br /> 18.Discrepancy # <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ) s j ❑Full Rejection <br /> ❑Residue ❑Partial Rejection <br /> r <br /> Manifest Reference Number. J <br /> 18b.Alternate Facility(or Generator)' ► U.S.EPA ID Number <br /> J <br /> ua. <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazarlous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 2. 3. 4. <br /> 71 <br /> 20.Designated Facility Owner erator.Certification of rete f hazardous materials covered by the manifest except as nPpI in Item 18a <br /> Printed/Typed Name J Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY T7 GENERATO <br /> 1) 11249/156017 <br />