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1pt� �rp- h'i Z5" o065z06773K3 <br /> Please print or type.(Form designed for use on elite(12-pitch) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number 2.Page 1-7F3 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL_000433477 1 I 1-1300-468-17-C-,10 10065 2 0677 SKS <br /> 5,Generators Name and Mailing Address Generator's Ske Address(if different than mailing address) <br /> 5 `-?9 At ,Iai:P5t'-mi i xii- <br /> RI1='OC. =5366--10000 <br /> Generator's Phone: -599 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY-Ki_.EEN SYSTEMS, INC TXR00008I205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARt�ORS ENVIR17NMFNTAt. SVC INC. MA>03937�22510 <br /> 8.Designated Facility Name and Site Address EPA ID Number <br /> CLEAN IA 2PCfR CI a/4'N�S� <br /> 1 , w <br /> i /bad ava"pisf9 1RA�+ 4ill 4.5[33 CA0�jq310 <br /> Facility's Phone: ' <br /> ga, 9b.U.S.DOT De 'ptior(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WLNol. 13.Waste Codes <br /> 1. NON-RCRA HAZARDOUS WASTFt SOLID 8 Di, t J bD P <br /> (OIL. FILTERS) <br /> W <br /> Z 2. <br /> W <br /> r9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> TenAWI 0.7 CSr. <br /> � �7 1=''t HR EMERGENCY 'L'H =' 3K ';Flt r <br /> c. - - c <br /> 15. G NE T R'SIOF ER 'SCE I ICATI N: ereby declare that the contents o this consignment areiullyand arx:uralely described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations.It export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknoWedgment of Consent. <br /> Icedity that the waste minimization statement Identified In 40 CFR 26227(a)(if I am a large quantity generator)or(b)(dl am a small quanti a tor)is true. <br /> GenemtorslOfieror's Printedlfyped Name Sign Month Day Year <br /> Wlyms Q <br /> J 16.International Shipments <br /> i= C1 Import to U.S. ❑Export tram . . Pc entrylexit: <br /> Transporter signature(for exports only): leaving U.S.: <br /> LX17.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> Tran iter 1 PrintedlTyped Name Signatu "4/f, Month Day Year <br /> a <br /> U) !^+ y!/11 Vn <br /> Z ed Typed Name ly Sign Month Day Year <br /> -7 l3 r?3 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Pam'ai Rejectionj <br /> Full Re ecdon <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone <br /> W 16c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Zz <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3 4.41 1 <br /> 20,Designated Facil 0 r or Operator.Ceillification ofrgoqt of hazardous materials covered by the manifest exce as Vin Item 18a <br /> Printedrfyped Name 1 Signature Da <br /> i I�r'417 <br /> EPA Form 8700-22(13• Previousedl onsareo ete. DESI NATED FACILITY TO DESTINATION STATE OF REQUIRED) <br />