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SSL SK SHIP# 232179997 IiiiiiiiiiliiiiiiiiiiI1iiImiHiI f iI <br /> 0077713665 K$ <br /> Please print or type. Form Approved,OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number TX R000681205 2.Pagel!of 3.Eme Y ResfroAse Ehane 4.Manifest Tracking Number <br /> WASTE MANIFEST 11 4GiS 1�G 1007771366 SKS <br /> S.Generators Name and Mallin Address Generators Site Address(it different than me lin address) <br /> SAFETY–KLEEt� SYSTEMS, INC. <br /> SAFE SYS SYST MB, INC. <br /> PO SOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generator's Ph— 209-545-1011 SALIDA CA 95368 <br /> s.rrdyygarterl.Cogygn� SYSTEMS INC U.S.EPA ID Number TXROOOO81205 <br /> 7.Transporter <br /> l2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> S.Designated Facility Name and Site Address THERMO FLUIDS INC U.S.EPA ID Number <br /> 12533 SE CARPENTER DR <br /> CLACKAMAS , OR 97015-8988 <br /> 503-788-4615 OR0000025197 <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description[including Proper Shipping Name,Hazard Class ID Number, 10.Containers 11.Total 12.Unit 13-Waste Codes <br /> HM and Packing Group if any)) No. type Quanhty M.Nol. <br /> NON–RCRA HAZARDOUS WASTE{� SOLID DM P 223 <br /> !DRAINED/UNDRAINED USED UIL FILTERS! <br /> Z 2- <br /> w <br /> C9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD C TPO SAL CSG: <br /> 24H EMERGENCY#800-468-1760–CH/SK/TFI–Contract retained by generator confers a envy authori y <br /> on initial transporter to add or substitute additional trans orters on ener=rls behalf. <br /> 15. GENERATGR'SfOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects In proper condition for transport according to app4icable international and national governmental regulations,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 C Rent. <br /> certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity genera[ )or(b)( am a sm ntity generator)is true. <br /> Generator'slOfferors Pn ffypedN Signa[ Month Day Year <br /> 16.In emotional Shipments <br /> L1S. FI Import to U. Export from U.S. Port of entrylexik <br /> ? Transponer signature(for exports only): Date taving U.S.. <br /> tY 17,TransporterAcknowledgment of Receipt of Materials <br /> w <br /> Transpo er 1 PdniedlT Namell� signature Month Day Year <br /> O �tillilili <br /> CL <br /> 2 Transpo PrintedlTyped sire Signature Month Day YeIr <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue Ll Partial Rejection Pull Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> uL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> Fn 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. I 2. 3. 4. <br /> } <br /> r <br /> Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> tedlTyped Name Signature S Month Day Year <br /> e r vv. 'SJ lO IZ116 <br /> EPA Form 8700-22 Rev.12-17 Pre ous editions are salete. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br /> 1)7872676/15603 <br /> OR14472_WT_007771366SKS 19 <br />