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SSL SK 8141P# 227956217 'Please print or type Form Approved.OMB No.2050-0039 UNIFORMIJI RDOUS 1.Generator ID Number 2.Page of 3. me R e P 4.Manlfest Tracking Number CAL@0034&t37S 1' -� -- � ' ' 0069 3442 SKS WASTE ANIFEST 3.Generators Name and MailiAddress Generator's S•te dress(if diff rent than aifn address) ADE w Goluen Sate AD _ Go den 'tale 18301 West Stanford Rd Attn Samuel Ichenry 18NI Stanford Rd TRACY CA 95377 Attn Lester Sabo Generators Phone: TRACY CA 95377-9708 6,Trade GomA�n , SYSTEMS T MS INC U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address SAFETY""KI..EEN OF CALIFORNIA U.S.EPA ID Number 6880 SMITH AVE® 00 NEWARK ' CA 94560 CAD98088'741 S 10-795-44 Facility's Phone: 9a• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt./vol. 13.Waste Codes 0- 1- 1 SON C HAZARDOUS TASTE, LIQUID TT G 221 91Ei w rz 2. C9 3. 4. 14.Special Handling Instructions and Additional Information TS A IA VSD 1 SS 24H C CRS NCY 800-4SSm-1760—CH/SK/TFI-Contract retained by generator confers aency authorai y an initial transporter to add or substitute additional transporters on generaV0125 bohaZfr 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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAckhowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if l am a small quantity generator)is true. Generators/Offerors Printedfrypedd N, ne Si ture "'" Month Day Year cry �er ;t�__.. / 16.International Shipments i' Z 1:11 mport to U.S. El Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17.TransporterAcknowledgment of Receipt of Materials LLJ Trans rl r1,/Printed/Typed W Sig tur Month Day Year Oa +;srr''� (� Transporterrinted/Typed Name Signature Month Day Year F- 18.Discrepancy „ 18a.Discrepancy Indication Space ❑ Quantity ❑ Type ❑Residue ❑Partial Rejection ❑Full Rejection s Manifest Reference Number: ,` 18b.Alternate Facility(or Generator) U.S.EPA ID Number i Facility's Phone: J 18c.Signature of Alternate Facility(or Generator) Month Day Year 1 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1' 2' 13. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year }o4rrt QO2( 1 Previous editions are obsolete. GENERATOR'S INITIAL COPY ( 6t