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*Y ?185-01ri USC 00476. 0758 - <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator IDumber 2.Page 1 of[3T_Em_erge7;c;4_FPesponse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000287336 000683594 SKS <br /> 5.Generator's Name and Mailing Address% Generator's Site Address(if different than mailing address) / <br /> KWIK HART <br /> 950 W 11TH ST •, <br /> TRACY CA 95376 <br /> Generators Phone: 92S-989-1561 <br /> 6.Trans rter 1 Company Name U.S.EPA ID Number <br /> SAFETY-KLEEN SYSTEMS, INC. TXR000050930 <br /> 7.Transporter2 Co e U.S.EPA I Num) <br /> � <br /> B.DesignatedFaclliryNameandSite*dress SAFETY-KLEEN SYSTEMS, INC. 000618 U.S.EPA ID Number ' <br /> 1722 COOPER CREEK ROAD <br /> DENTON, TX 76208 <br /> 940-483-5200 TXD077603371 <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including ProShipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> and Packing Group d an Quantity WtNol. 13.Waste Codes <br /> HM n9 A( Y)) No. Type �' <br /> X hQ WASTE GASOLINE DM P D001 D008 018 <br /> 0 3 UN1203 PGII (D00 ,DO18) 212 UT <br /> LU 2. <br /> W <br /> C7 <br /> 3. <br /> ' 4. <br /> 14.Special Handling Instructions and Additional In ration <br /> SK TRCK#109113406 0003172964 <br /> 1)ERG#128 <br /> SK AUTH'D TO USE SUBS�OUENT C <br /> 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 ce"that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> certify that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(f I am a small quantity generator)is true. <br /> Ge eratoesl0fleroes Pnnted/Typed Name Signature Month Da Year <br /> e <br /> _J 16.International'Shipments <br /> j 1- ❑Import to IU.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LLA 17.TransporterAdmavdedgment of Receipt of Materials <br /> ` TransMA) <br /> dnted/Typed Na Sign Month Day Year :r <br /> O <br /> a <br /> H <br /> Q Trans a(! yped Na Mo th Ye <br /> ir <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑R ue ❑Pan W Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facllitys Phone: <br /> W 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> ' � 1. & 2. 3. 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 Signabrre Month Day Year <br /> SKag.& Oat <br /> EPA Farm 8700.22(Rev.3-05) Previous editions a e obsolete. DESIGNATED FACILITY TO GENERATOR STATE(IF REQUIRED) <br /> 1)0001086 2 3) 4 10303.0770 <br /> 1)200155889/40238478 <br />