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SSL SK SHIP# 227088742 11111111 llllllllili 111111 <br /> 0 0 6 6 3 7 0 1 0 S K 6 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator to Number -). R� i � 2Pago�t of 3.Em8r0.gnGV R4spggse thyme 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 i3mlCr 9C tl 00 <br /> 6687010 S K S <br /> 5.Generalofs Name and Mailin Address Generator's Site Address(if differen'' '7 <br /> than mailin address) <br /> SAFETY—KLEEfe SYSTEMS, INC. SAFETY—KLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209-545-1011 SALIDA CA 91,]368 <br /> B.Tr r"fQ-Wn SYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.TranspoRer 2 Com Name U.S.EPA1D Number <br /> C!_EAN HRyPORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address THERMO FLUIDS INC U.S.EPA IO Number <br /> 12533 BE CARPENTER DR <br /> CLACKAMAS , 4R 97015-8989 <br /> 503-788-4616 0170000025197 <br /> Facility's Phone: <br /> 9a. 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 Groupl9any)) No. Type Quantity Wt.Nol. <br /> NON-RCRA HAZARDOUS WASTE SOLID � DM � P 223 <br /> o (DRAINF_DJUNDRAINED USED b1L FILTERS) <br /> 2 2 <br /> LU <br /> t7 <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information TSD:TPO SAL CSG: <br /> 24H EMERGENCY#400-468-1760-CHISKiTFI-Contract retained by gener^at Dr confers aggenvy authori y <br /> on initial transporter to add or substitute additional trans arters on eneratar'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 dassfied,packaged, <br /> marked and labeledlplacarded,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 certify that the waste minimization statement identified in 40 CFR 262.27(a)(T]am a large quantity generator}or(b)(if i am a small quantity generator)is true. <br /> Ge a rOlferofs Pr /Typed Name Signature Month Day Year <br /> a LA �� v <br /> 16.Intern 'anal hipments <br /> Ju- ❑Import to U.S. ❑Export from U.S. ort enhylexit <br /> i Transporter signature(for exports onll at as ng U.S <br /> X 17.Transpoder Acknowledgment of Receipt of Materials <br /> T er 1 Pdnted(Fy Name Signature Month Day Year <br /> la / vlq <br /> QTranspo r2 P tedlTyped Signature Month Day Year <br /> F ` U <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> till Alternate Facility(or Generates) U.S.EPA ID Number <br /> J_ <br /> tl <br /> Facility'.Phone: <br /> w 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Z <br /> cnFn 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Lu <br /> o 1 4 2. 3. 4, <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous matarials covered by the manrfest except as noted in Item 18a <br /> PdnledfTyped Name Signature Month Day Year <br /> c � l <br /> �7 i ` <br /> EPl 8I262J11 1551 Previous editio are obsolete. DESIGNATED FACILITY TO EPA's a-M NlFEST SYSTEM <br /> Ol4472_WT_006687011 597 <br />