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53 13K S14TP# 32115617 111111I 1111l11 <br /> 0069519105 KS <br /> Please print a pe. Fon Approved.OMB No.20504X139 <br /> 1.Genaaor 10 Number 2.Pega 1 of 3 l MMIM Track Nw— <br /> N��MWEST <br /> S TXRPP00E11205 1 -" ° �� 06 5191 SKS <br /> 5.Geneabts Naas and Madry Addeo fWWMfs Sim AOM(itd'dmrat Born MMSg address) <br /> SAFETY-KLEEN SYSTFM9, INC. SAFETY--HLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SAL TnA PI-VD <br /> SAL TDA CA 95368 <br /> Gowamrs Phme: 2209-545--1011 1 SAL_IDA CA 95358 <br /> US.EPA I)Number <br /> s Tr }Y- , SYSTEMS INC 1'xa000061205 <br /> T Twspmlar2 Carlpany Nene U.B.EPA IO Metier <br /> CLEAN HARBORS ENV SVC INC. <br /> MAD0..9322250 <br /> 8.Designated Fadlky Name and Silo Address SAFETY-HI-FEN SYSTEMS, INC. U,S.EPAIDWffrf r <br /> f•000 M. TH STREET <br /> SACRAMENTO , CA 95828 <br /> 91.6-.',86-4913 CAv MON4517 <br /> F s Were: <br /> %HM and S DOT <br /> Group(d anQf any) ng W� Name.(Ward Corsa.ID Mob, 10.Corlui s 11.Totw 12.Ure 13.Waste CodaNo. Typo OueMy y Abl. <br /> C <br /> 7 11 <br /> OQ <br /> w <br /> w 2_ NON-RCRA HAZARDOUS WASTE, LIQUID OM <br /> (ADUEOUS PARTS WASHER SOLUTION` <br /> 3. C� v <br /> i94 At <br /> 4. <br /> u.SPocWHmM6pkrebaiarandAeS&wmramemn 'TSD:SCA SAL. CSs: <br /> 4H EMERGENCY#600-468-1760-CH/SK/TFI-Contract retained ny generator confer- a racy aothori y <br /> initial t P tadditional half, <br /> 1S CENERATOW&VFFEROR9CO F1CATWN:ihmbyded"uwae caMenM of7amreigimm ea/ukysMx aidydesoibedabmbyt*PMOar04*4nere.xdmdaaWood,padapd. <br /> marked ad mbdeNpmcgded,swam r al respect n p wwnT*(Xl mrtrarepnlaoddmng lo appiraw MamsfioWand nawwI gwwnonml repaa&n.neapMaWwward I tm le Pdmry <br /> E*amr,loarfaytlet de odntarilo of this m OWst Wrdorm m Mcorms otfMatlWW EPAAckiwNW47erdofCasae. <br /> IoeMy dot the wasemk*malon slalsowa idwdW n 40 CFR 262.27(a)(K l am a terga gwbiy geneamp a"ema smell qwday gmaala)is hue. <br /> slplads , yped Name SUWWMaoIN pey <br /> f8.1 SNpm M <br /> ❑ewatwuS. ❑ExpdkdmU.S. ofe Wexit <br /> M Tmnsmw algtiaere(for expars ody): mmawng U.S.: <br /> W 17 TMWrIMACFWAftra*o(R*c Nof M&nais <br /> n 1 Name Monts Day Yee <br /> a 8 00 <br /> n <br /> Mona, Day Year <br /> c 1 <br /> i18.Dwepency <br /> 18a.Daawwcy IndaIM Spee ❑ Q b ❑Type ❑ResMie ❑Palw R Wbm ❑Ful RWb. <br /> Merilaat Remrerce Norther: <br /> 18b.AkmW Fso®ly(aGaemmr) U.S.EPA IO Numba <br /> J <br /> U <br /> W Fackys PhI a: <br /> w 1&.SgrebreoFAllmae Fac ty(a Gererea) Momh `/ear <br /> 6 <br /> 2 <br /> H19.Hazardous Wase Rwwt Maiagarwnl McBwd Codes(i.e..codes fm hmmFdds wage rsaii,"depoW,and eymann) <br /> 1. L 2 H141 & 4. <br /> 3. <br /> 10 Delq and Fadki purer a OWala-CeMwaron of raeiptM haradoua mbiala Dived by the manftsIswoo w noW m Nam 18a <br /> /111 Name ria <br /> EPA Form 8700- .1 -17 Prem edftm are ESIGNATED FACILITY TO EPArs a-MANIFEST SYSTEM <br /> 2)14941/156023 '` ''.,rz-r�=.i•-rra,i ca <br /> a�� Fn.r— <br />