Laserfiche WebLink
State of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9.30.991 <br />Please print or type. Form designed for use on elite (12 -pi, sewrir81- A S - n T <br />C <br />n <br />CS <br />Le <br />OF <br />a <br />q;*a <br />!i b a <br />C <br />LL <br />C L <br />Z <br />M <br />3 <br />a <br />Z <br />C <br />. a <br />Z <br />LL <br />t— <br />a <br />V <br />� VI <br />oc <br />0 <br />See Instructions on back of A 6. Department of Toxic Substances Control <br />Sacramento, California <br />f 45{ DO NOT WRITE BELOW THIS LINE. ; <br />PRQL# A+94e40-10-24-1 0)0009030400 <br />SMPL# A X44"-8 B ), 8 C.)QO8Q04VAPOR IENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />DTSC 8022A (1/99) Tp P.O. Box 400, Sacramento, CA 95812-0400 <br />EPA 8700-22 <br />UNIFORM HAZARDOUS <br />1. Generator's US EPA ID No. Mo <br />it Document No. <br />'e. Pagel Information in the shaded areas <br />is not required by Federal law. <br />WASTE MANIFEST <br />(,° 0 0 6 4 <br />of i <br />GNOME 1N <br />33y Generator', orNO,a�te I MailingAdddressRD <br />A. 5 a e Manifest Document Number <br />23354346 <br />TRACY CA 95377 <br />B. State Generator's ID <br />A. Generator's Phone (.209 )8 31.0— 5 34 3 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID ]Reserved.( <br />SAFETY—KLEEN SYSTEMS, INC TXR000050930 <br />D. Trapsparter'sFhane . <br />8da_ 669-5740 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID (Reserved.] .. <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 000658 10. US EPA ID Number <br />G. StatV iLityd f 3 '48 0 <br />!C lJ <br />SAFETY—KLEEN SYSTEMS, INC. <br />H. Facility's Phone <br />3700 LAGRANGE ROAD KYD053348108 <br />SMITHFIELD KY 40068 <br />502 84S=2453 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers 13. Total 14. Unit <br />No. Type Ouantity Wt/Vol I. Waste Number <br />Stole <br />G <br />LIM <br />N6. <br />Ir AjdMART <br />State <br />EL <br />EP'A/Other <br />T <br />WASTE SOLIDS CONTAINING FLAMMABLE <br />sl°t° 213 <br />O <br />LIQUID, N.O.S. ( GASOLINE, BENZENE) 4.1 <br />DM D P EPA/Other <br />R <br />UN3175 PG II (ERG#133) <br />1 DOOi <br />d. <br />State <br />-1 EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />IC) D018 <br />°--- 4-C <br />C. <br />d. <br />14 <br />15. Special Handling Instructions and Additional information MFST <br />R/ 05124058 0002-8617-22 <br />EMERGENCY RESP 800-468-1760(24 HR). IF UNDELIVERABLE RETURN TO GENERATOR. <br />SK CORP AUTHORIZED TO RETAIN LICENSED SUJBSEQUE-NT <br />CARRIERS AS NECESSARY. <br />5M <br />-fit <br />SKDOT# A: -2t8 O <br />$': C: 34273 D: <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed, <br />marked, and labeled, and are in all respects in proper condition for transport by highway according <br />to applicable international and national government regulations. <br />IF I am,a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br />practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health <br />and the environment; OR, if I am a smdll qucintlty generator, 1 have made a good-Foith effort`mini <br />ize m waste g eration and select the best waste management method that is <br />available to me and that I can afford. <br />Pyated/Typed NameSienalul <br />t <br />Month Day Year <br />1t <br />zil( / <br />T <br />17. Trans rter 1 Acknowled ement of Recei t of, oterials T <br />R <br />A <br />Printed/Typed Name <br />Signot <br />Month. Day Year <br />Kd <br />P <br />0 <br />18. Trans orter 2 Acknowledgement of Receipt of Materials <br />RPrinted/T <br />T <br />ed N <br />YP Name <br />Si nature <br />g <br />Monti Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />A <br />C <br />L <br />I <br />20. FacilityOwner or Operator Certification of receipt of hazardous materials <br />covered b this manifest except as noted in Item 19, <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />Y <br />f 45{ DO NOT WRITE BELOW THIS LINE. ; <br />PRQL# A+94e40-10-24-1 0)0009030400 <br />SMPL# A X44"-8 B ), 8 C.)QO8Q04VAPOR IENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />DTSC 8022A (1/99) Tp P.O. Box 400, Sacramento, CA 95812-0400 <br />EPA 8700-22 <br />