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Please print or type.(Form designed for use on elite(12-pitch)tyv.wriler.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14,Ma fe Tr k r �+ WASTE MANIFEST CALQOOI63163 I 1-800-468-1760 U77-1 SKS 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) CENTRAL. CA KENW©RI t9 10998 5 HARLAN RD FRENCH CAMP CA 95231 9600 Generators Phone: 209-983"6970 6.�rgr�Qr�r_J Cpmpg fhm SYSTEMS, .S.EPA ID Number Ht'k T 1SLGETI INC,--rNc.- TxRao0050930 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS, INC. 000760 U.S.EPA ID Number 6000 BOTH STREET SACRAMENTO CA 95828 Facility's Phone: 916-386-4913 CA0000084317 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)) 13.Waste Codes No. Type Quantity WI.Nof. o X "WASTE PAINT RELATED MATERIAL, 3, UN1263, l DM P F003 D001 D018 Pa Us i D035 D039 212 W 2 3. 4. 14.Special Handling Instructions and Additional Information SK TRCK#111232621 0040700283 0009040990 1007 22 1)ER00128 24 .HR EMERGENCY # 800-468-1760(SAFETY-KLEEN - 94138) � SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY 15. GE ERATOR'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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable in4rnational 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 EPA Acknowledgmentof Consenl. I certify that the waste minimization stalemenl identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(KI ali a mall quantity generator)is We. G eral slOfferorsl 'ntedlTy me S' ature Month Pay Year ukVj\tL Tj 4,P -.1 16.Intafnabohl Shipments ❑Importto U.S. ❑Export from U.S. Pod of entry/exit Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Re ipt of Materials Transpo dnled/TName Signaturo Month Day Year IL ITranspoRer 2 Print yped Name nature Q 9 Month Day Year W 18.Discrepancy 18a.Dlscrepancy Indication Space ❑ QuantityType ❑ ❑ j ❑Full Rejection ❑T Residue Partial Reaction Manifest Reference Number: 18b.Alternate Facility(o(Generator) U.S.EPA ID Number U Facilitys Phone: W 18c.Signature ofAltemate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. H141 2. L 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as 20pn Item 18a Prin1WTyD1d twme � Signa Month Day Year PA Foam @700-22 Rev.3-05 Previous editions are obsolete. O )O"el 607(2) ) 3) 4) SIGNATE FACILITYTO GENERATOR STATE(IF REQUIRED)