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SSL SK SHIP# 228107461 11111111111111111111111111 oil 1111111 <br /> 0 0 6 3 9 1 6 9 3 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number CAT000613968 2.Pagel of 3. E Wpply Rasp r Pm, 4.Manifest Tracking Number �/ <br /> WASTE MANIFEST 1 1 tsr010 xtbC I/ 006391693 S ESS <br /> 5.Generator's Name and Mailing Address Generatofs Site Address(if different than mailing address) <br /> SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> GeneratorsPhane: 209-'545-1011 1 SALIDA CA 95368 <br /> 6.Tr2pS0oderlC—TL'Llame SYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.Transporter <br /> I2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC, MAD039322250 <br /> 8.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 ORli000025197 <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(inciuding Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit <br /> HM and Packing Group q any)) No. Type Quantity WWol. 13.Waste Codes <br /> 1 NON—RCRA HAZARDOUS WASTE SOLID i DM ?1 P 223 <br /> Ix (DRAINED/UNDRAINED USED bIL FILTERS) CJ <br /> 4a <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:TPO SAL CSS: <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retained by generator confers a ency authori y <br /> on initial transporter to add or substitute additional trans nrters on enera?or's behalf. <br /> 15. GENERATOR'SIOFFEROR'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 applicable 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 Consent. <br /> I rMY that the waste minimization statement identified in 40 CFR 262.27(a(if l am a large quantity generatol am a small quantity generator)is true. <br /> Ge t slOfferl Prin d Name SignaMordY �e <br /> fTf <br /> rj 16.Intema nal S i menu <br /> Z ❑Import to U.S. ❑Exportfrom U.S. Port (entiylexit: <br /> Transporter signature(for exports only): leaving U.S.: <br /> Wns 17.TrerterAcknowedgment of Receipt of Materials <br /> OT spo r 1 Printedlfyped Sgn re/ MonthD <br /> N6u 0 `!I� <br /> C Tran r 2 Prin !Typed Name Signature <br /> Mon m Day Year <br /> 117a <br /> r <br /> 18. iscrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residuetecti ❑ ull Rejection <br /> ❑Partial Rejection F <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LLF-Myra Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Lu <br /> 0 1 � � 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name Signature Month Day Year <br /> L 5 <br /> EPA ioi1M699v1�b10 ious editions ail obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> OR14472_WT_006391693SKS 595 <br />