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SSS SK SH.IRt# 22162:521 <br /> Piease print or type.(Form designed for use llll an etite(92ptitch)typewriter,) � � 1 7 4 2 d 5 8 S K S <br /> UNIFORM HAZARDOUS t.Generaatxx!D Nurnt er 3 Farm Appro`red,LIMB No.2950-0039 <br /> LA09 4 2.Paqqiof 1� y`{ �yE� 4.MaME <br /> t "ra�ciciargNumbar Q (� <br /> fear YYASfE MILNtFfwSC �'Et��f yf 4i3 VGenesat�'S}Jame and ng Add s <br /> Ca 1-T r�a h s Th op 0- Lodi cane tors$ite Address(ifditfarard than m "ng a{€drffs, . <br /> 1603 S B St �a1-Tram Shop ;V ML <br /> STOCKT€N CA 95206 845 E Pine Sit <br /> Generator's Phone: 209-333-6953 <br /> s.T L G I CA 9s240-3108 <br /> �'�°`�"L SYSTE�ES, TttlC. U.S.EPA 1pNurnber <br /> TX 0000 <br /> 7 Transporter 2Compan7 me j <br /> t/L� U.S.EPA E�r� v" <br /> 8,DesignatedFaeil#tyName andSite Add ress 5AVETY-FtLEEN SYSTEKS.: INC. <br /> 6000 SST( STREET <br /> U.$.El'A1➢Number <br /> 916-386-4913 SACRAM TO �PS82a <br /> FaitiysPh w CA0000064S17 <br /> ga 8h.U.S.DDT D-000n(ir1l Paper Six'pairg Nana,Hazard Class.ID Number. <br /> Hth and FaCkjng GrouA(if arry)) i[t.COniainers 11.Total 12,Unit <br /> No. Type Quantity M.Aro€. 13,Ylfaste Godes <br /> 1. [ f ' CiF! F4AZARVou iJ 11; , LTt UIi3 a (AQUEOUS BRAKE CLEANERS DF G 17 <br /> F! <br /> f <br /> (AGl1Hf S `ARTS WASHER SO liTI'UN) Dil 4 <br /> s AD --- <br /> 4. <br /> �"��14.5pardal Nandf;Og ln3hli�ans artd� trrloatttat�rs <br /> 24 HR EMERGENCY #1-800-468-1760 ASK / TFT) Z-1 <br /> V <br /> AUTH AS "AGENT-FOR" BY GEN TO RETAIN LICENSED ,SUB CARRIERS � NECESSARY C:ES SSARRY�`- <br /> 15. GENERATOR'SICFFEROR'S CERTIFICAT)OH: 1 he eby dec�re f#ratthe nonteafs Lis cons g uru nt a rlty ara1 accura� d <br /> marked and lab+sedfpat�rded.and are n apt fy eWibed above by Lha proper shipping name,aril are dassifled,packaged, <br /> respects n proper CE�rdit Wl for tranv�ort accord;u3, aFPtlral�e irnem ocneand rpado al govemrnerrfa regulations.If expert 8rd f am the Pr4nary <br /> Exporter.I cttr%,that the contents of this cons(gnrnsnt mnfl to the bums of the afta[hed EPAAckrrowiedgment of Consent <br /> r rarefy that the waste rn in"2atimt statewt idonffil in 40 CFR 26227{a)(t!am a targe quan+ijry generator)orbi if I 5 1 <br /> am a u <br /> e+aReratYA VDff M?s PrtntedrTyped N me ( ( q .ry 9enerat�rj rs tr.,e. <br /> T= <br /> nature r <br /> ►'L 4C/t p <br /> � 16.lntemaiiaaa!Shipments t <br /> El Impart to a 5. ❑Export flU.S. Port of t v <br /> -4 Transporter signature(far extorts onb/): <br /> edgrrrant <br /> ;Data{e US-: <br /> 17.TransporterAdooli of f pt of MalonaN <br /> Tra or 1 Print yped Name <br /> Signattxe Month Day Year <br /> � Trona T Nartra <br /> It( r ! <br /> Signature htrxti4r Year <br /> 1&91screpaar <br /> 18a.©s,raparcy€nd4a6cn Space Ctuanity �T <br /> Ypa LJ Resxtue ❑Portia'qaisciion ❑FUl Rq,eedcr <br /> lab.Aftemale Fad§V(or Cenerator) h ` Ke€esence Numb¢r <br /> J IJ.S.EFAID Number <br /> C3 <br /> Fadttys Flh+one: <br /> 18c:Signature cf Aftemate Facloy(of=ralor) <br /> 7Month pay Year <br /> 1 S Hazardo s Waste fiapoA Ma Daman[Fttsotl Codas(t.a-:Wd9g'Or hexa dors waste UeatruarL d spoasi,and <br /> recycling syslems) <br /> G 1" H141 2. Et141 3. a. <br /> E?eSigneted F taffy Owner ar Qperafor.Certficallon of rel Of hazardous Materials onrered by the manifest excepl as nmd in Item 18a <br /> Ana Martyr�DqY- <br /> EPff <br /> � � � p <br /> � ° GESI AT C TACILITYTCS DISTPWION STATE(IF REQ€ IREDj: <br />