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SSL SK SHIP# 2.30026589 <br /> r " 0073121575 KS <br /> Please print or type. Form Approved.OMB No.20�i(1-0039 <br /> UNIFORM HAZARDOUS 1 Generator Ip Number 2.PagF 1 ef, R e P 4.Manifest Tracki Number <br /> WASTE(MANIFEST rX R1�00081 r0 5 ,. , � � 7�� `fb� WO 0073 1215 7 SKS <br /> 5.Generators Name and Mailing Address r (ienestors Site Address(if different than mailing address) <br /> SAFETY-KLEEN SYS-EMS, INC. SAFETY-KLEEN SYSTEMS, INC. <br /> PQ BOX 555 5050 SAL-IDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209-•545--1011 SAL I DA CA 35368 <br /> '. <br /> "'Writs— 1 n61 SYSTEMS INC w: U.S.EPA Number <br /> b T X R 0000Ei 1221E <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. !+1AD039322250 <br /> 8.Designated Facil ty Name and Site Address SAFETY—KLEEN SYSTEMS, INC. U.S.EPA ID Number <br /> 6000 BETH STREET <br /> SACRAMENTO , CA 9582`#) <br /> 916-386-491,3 <br /> Facility's Phone: rA0001710a 4517 <br /> ga. I 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contac ers 41,Total i2.Unit <br /> HM and Packing Group(if any)) <br /> No. Type Quantity WtJVW. 13.Waste Codes <br /> 1. <br /> 0 E C1 '— <br /> nrLU <br /> ,Zit z. N❑N RCFtA HAZARDOUS WASTE LIQUID DM r �?4 <br /> (AGUE❑US PARTS WASHER S❑L❑TI❑N) <br /> 3. <br /> 7 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD SCA SAL I'SG <br /> 2414 EMERGENCY#800-468--1760-CH/SK/TFI-Contract retainl6d by generator confers agency authori -y <br /> on initial transporter to add or substitute addition I trans rters on eneratar' s behalf. <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and a rately described above by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable intematio I and national governmental reguiations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Co nt. <br /> I certity that the waste minimization slaternent identified in 40 CFR 262.27(a)(if I am a large quantity generator)_w<i am a small quantity generator}is true. <br /> Gw6rakeslOfferors Khtyped Name Signet a Month Day Year <br /> 16.IMernalial Shipments <br /> ZImport to U.S. ❑Export from U.S. it, <br /> of enhVexit: <br /> Tran'sporter signature(for exports only): leaving U.S.: <br /> dr LU <br /> 17.TransporlerAcknowledgment of Receipt of Materials <br /> n iter 1 Pri d yped Name <br /> IL Signature Month Day Year <br /> LA <br /> Z ranspo �2 Printedrrype�e Signature <br /> Month Day Year <br /> 18.Discrepancy <br /> 16a.Discrepancy Indication Space <br /> ❑ QU.Nity ❑Type ❑Res'ue <br /> ❑Partial Rejection ❑Futl Rejection , <br /> Manifestference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J > <br /> U <br /> LL Facili 's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous wa6e treatment,disposal,and recycling s tems) <br /> LU 1 �_ T1=I, <br /> 41 3. 4 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest ex s noted in Item 18a <br /> Pn t a e yly Signa Month Day Y <br /> JV� m <br /> EPA Form 870 -22 Re 2 17 Previous editions areobsol IGNATEUqAl TYTO A's e•MANIFEST 5Y5TEM <br /> �4941I15602? �-�� <br /> y <br />