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�� 71 <br /> ' Please print or pe.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050.0039 <br /> e UNIFORM HAZARDOUI <br /> Generator ID Plumber 2.P t pf 3 E e se 4.Manifest Tracking Number' <br /> WASTE MANIFEST C��163163 1-" � �s 003329924 F L E <br /> 5.Generat s Name an ailing Address Generato-Site Address(if different than mailing address) <br /> CENTRAL CA KENWORTH <br /> 1MB HARLAN RD <br /> CAMP CA 95231-96M <br /> Generator's Phone: 209-983-6970 <br /> 4 a SYSTEMS, INC. U.S.EPA ID Number TX ROSOM930 <br /> 7.Transporter 2 Company Nalne U.S.EPA ID Number <br /> B.Desgna acliity ameands"Address SAFETY—KLEEN SYSTEMS, INC. U7. 1D Number <br /> 6008 88TH STREET , <br /> , CA 95828 916-386-4913 CASON084517 <br /> Facia' s Phone: , <br /> ga. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> r No. Type Quantity WI.NoI. <br /> r X 1 RQ WAFE PAINT RELATED MATERIAL DM P D081 I D018 D035 <br /> 0 3 L�VlP63 PGI I (D001) A0 <br /> l ,.�— <br /> r 39 D040 212 <br /> Z, 2. <br /> LU <br /> 3. 1 <br /> 1 <br /> A - <br /> 4. <br /> 14.speaal Handling Instructions and Additional Information SK SHIPO5089 r 9040990 2011019 CSG 122 <br /> 1)ER8081283�� 2UO 83 774Y <br /> 24 HR EMEME�Y 01—TO 8468-1760 (SAFETY—KLEEN — 94138) <br /> LICENSED SUBSEQUENT CARRIERS AS Y �' 1.• <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the conterits of this consignment are fully and accurately described above by the proper shipping name,and re i led,packaged, <br /> marked and la¢ebdlplacatded,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 cerlffy.that the contents of this oonsignment conform to the terms of the attached EPAAcknowledgmenl of Consent. <br /> I certffy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am rnat u5ntity goneratoi)is We. <br /> onerM=Q� <br /> igna re on ay ear <br /> 9 <br /> 1n1 ntZ 'Transporter <br /> prt to U.S. ❑Export from U.S. Port of entryloxit: .__- <br /> 'Trans er s' natu for exports only): Date leaving U.S.: <br /> 17.TransporterAckrawiedgment of Receipt of Materials <br /> `t <br /> O <br /> I ranspOrrpT 71Vrinleid/T qa Signature Month Day 7aar <br /> CIL <br /> TranspoW2 Print yped Narr4 to on ay ear <br /> F,- J �• <br /> 16,Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type .'y ❑Residue ❑Partial Rejection ❑-Nil Rejection <br /> �t. <br /> '•M nicest Reference Number: <br /> 18b.Alternate Facility(or.Generator) 1 U.S.EPA ID Number <br /> _J <br /> L) <br /> a. <br /> �- Facilit s Phone: <br /> uk,16c.Signature of Altemate Facllfty(or Generator) Month Day Year <br /> F-. <br /> Z <br /> '9:Hazardous Waste Report Management Method Codes(Lis.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Z0,QOgD.atedfadiity;Owrw or-Operator;Cergfication of receipt of hazardous materials covered by the manffest excep oted in Item 1 <br /> Printed am Signa Month Day Year <br /> Vi <br /> tB � Previous editio s are obsolete. DESIGNATED FACILITY TO GENER2A7t�R STAT '(iF EQUiFtED) <br /> 11))l �f0.37 <br />