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moi(_ SK SHIP# 227161431 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Pa e 1 of 3, m R s se 4.b06687690 <br /> ifest Tracking Number <br /> GAR000039:3.7th 9 i - '���-g � SKS <br /> WASTE MANIFEST <br /> 5,Generator's Name and Mailing Address Generator's Site Address(if different than '6A dress) <br /> Escalorl Preeber Brands Inc. <br /> 1905 Mchenry Ave Wo <br /> , <br /> ESCALON CA 95320-0000 <br /> Generators Phone: 209-552-6051 %t,, <br /> rt1p y.�y� S. Number } <br /> s.Trancuorlecl�C,ori�N SYSTEMS INC �� �[� T%R(D0tib0912435 <br /> kid t` r t <br /> 7.Transporter 2 Company I� a U.S.EPA mber Z_Z J <br /> 8.Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS, INC. U.S.EPA ID Number <br /> 6000 ReTH STREET <br /> SACRA`iri::NTO , CA 95828 CAp00�g4517 <br /> 916-386-4913 <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 Group(it any)) No. Type Quantity Wt.Nol. <br /> 1 NON- .:''.":(t H!"AZARDOUS WASTE LIQUID 3 134 <br /> o (AGUELiS PARTS WASHER SOLUTION) t _ <br /> �D 1 d <br /> z 2. <br /> w <br /> 3. <br /> El4. <br /> 14.Special Handling Instructions and Additional Information TSD:SCA 78664664 ES 12014 201 B50 CSG:21____� <br /> AH:-EMERGENCY#800-468-1760-CH/SK/TFI-Con tract retained by generator confer /ency authoril y <br /> on initial. transporter to add or substitute additional transporters on n ener or's behalf. <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I herb declare that the contents of this consignment are full and accurate) described above b theproper shi m name,and are classified,packaged,, <br /> t;Y 9 Y Y Y shipping Pa 9 <br /> marked and labeled/placarded,and are in all respects in`rroper 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generators/Offerors Pnnledlryped Name Signature Month Day Year <br /> r <br /> v <br /> ,j16.International Shipments ❑ ❑Export from U.S. Port of entry/exit <br /> � import to U.S. , <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> ►w— Tra porter 1 PrintedrF d N e S Month Day Year <br /> C=0 Transportet 2 Printed/fyp me 9fe` Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> _ an est.ReferEnce Numbeti—­­=, •- - - <br /> ._ .-'-- <br /> 186.Alternate Facility(or Generator) - U.S.EPA ID Number <br /> J <br /> U <br /> LL FacilitysPhone: 101 <br /> w 18e.Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> H141. 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 /> Prrledi7yped Name Signature Month Day Year <br /> EPl olrp 94017 Previous editions obsol e. DESIGNATED F CILITY TO GENERATOR <br />