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SSL 5K SH i P# 228053957 Please print or type. 0 0 B 4 5 4 2 5 7 5 K S 1.Generator ID Number Form Approved.i No.2050-0039 UNIFORM HAZARDOUS CAT0006 i 3968 2 Pagett of 3.Emej@ RQspr�jse P_hhppe_ 4.Manifest Tracking Number WASTE MANIFEST i CSIQ10— t7 1�ia1S 0 0 6 9 5 4 2 5 7 SKS 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) SAFETY-KLEEN SYSTEMS, INC. SAFETY-KLEEN SYSTEMS, INC. AC BOX 555 5050 SALIDA BLVD SALIDA CA 9531 Generator's Phone: 209-545-1011 SALIDA CA 95368 s.Tr � py� SYSTEMS INC U.S.EPA10Number TXR000081205 7.Transporter 2 Company Name U.S EPA ID Number CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 8.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, INC. I U.S.EPA ID Number 6010 88TH STREET SACRAMENTO , CA 5828 916-3854913 CA UOM4517 Facility's Phone: 9a, 9b.U.S.DOT Description(including i Shipping Name,Hazard Class,ID Number, 0.Containers 11.Tota! 12.Unit HM and Packing Group(if arty)] 0. Type Quantity WLN01. 13.Waste Codes o ' 1LIQUID w 2 I(AQL4EDUS ARTSDWASHEMJS WRSKUTION)D DM /► G 134 NM-RGRA to Im BF -1,34 3. (p 4, i 14.Special Handling Instructions and Additional Information TSD;SCA SAL CSG 24H EMERGENCY#BW-468-1760--CH/SK/TFI-Contract retained by generator confers agency authority an int ia1 transporter to add or substitute additional trans rters on generator's behalf. 15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and ac Lely described above by the proper shipping name,and are classified,packaged, marked and iabOedlplacarded,and are in all respects in proper condition for transport according to applicable intemation and nabonai govemmental regulations.If exporl shipment and I am the Primary Exporter,I call that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Con nt. I certify that the waste minimization statement identified in 40 CFR 262.271(if I am a large quantity generator)or(b) ' a small quantity generator)is true. Gen rslOfferors edffypedName Signature Movllth CDa Y J 16.lnte1/7 align Shipments ❑irni to U.S. ❑Export from U.S. Prt of t r.At: ? Transporter signature(for exports only): D vine U.5.: W 17.Transporter Acknowledgment of Receipt of Materials Tr spo r 1 Printed/Type d ame Signatu Day Year L a V) =2P Name9 Si re Month Day Year Name `� 18.Discrepancy IR I I 1Sa.Discrepancy Indication Space ❑ quart' �` ❑Type ❑Resi o ❑Partial Rejection ❑Fall Rejection 18b.Attemate Facility(or Generator) Manifest Rerence Number U.S.EPA ID Number J_ V ;� Facilitys Phone: i F10c.S(gnature Df Atemate Facility(or Generator) Month Day Year Z Fes 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) t 2. H141 3. 4, 20.Designated Facility Owner or Operator:Certification of receipt of hazardous malerials covered by the manifest except as noted in item 18a WTIL m " nature Mo Day Year CEPA Form 8701}-22 v. �7 revlous editions are 0023 . DESIGNATED FACILITY TO EPA's e- -E SYSTEM 17)1411 2114941l15G023 34494-17131