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i bSL. SK SH I P Q� 0i <br /> Please print or type. Form Approved.OMB No.2050-0035 <br /> UNIFORM HAZARDOUS 1:Generator ID Number 12.Page of 3. me({�gele,�i�y R�gg!Phpp 4.Manifest Tracking Number <br /> WASTE MANIFEST CARt9370 � �"—gIP10—�1b1i'-1 <br /> 0069.53303 SKS- <br /> Gene'ratDes Name and Mailing Address Generator's Site Address(if diff rent than mailing address) <br /> E calatl Preeier Brandt Inc. <br /> I05 Mthtnry Ave <br /> SCALON CA 95320-0000 <br /> Generat0Ys Phbne:• g-502-6051 <br /> 6.? o r U.S.EPA ID Number.SYSTtMS INC TXR000081205 <br /> ran'sporter 2 Gompany Name U.S.EPA ID Number <br /> :G .0()FtS!. ENVIRONMENTAL SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> �. SAFETY-KLEEN SYSTEMS, INC. <br /> rJ 6000 88TH STREET j <br /> SACRAMENTO , CA 95829 <br /> 916 86-4913 CA00MB4517. <br /> ttj�$Phoria: <br /> Ra.. 9b.U.S.DOT D%cdppon(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.WAste Codes <br /> 'HM and Paddng Group(if any)),. <br /> No. Type Quantity Wl.No1. <br /> a NON=RCRR HAZARDOUS WASTE LIWID DM G 114 <br /> (AGUEOUS PARTS WA§ftR aUTIQN) <br /> �"•• b� fid � <br /> 03 <br /> 2., <br /> W <br /> 3. <br /> RL1 I <br /> LSy I <br /> Specie}Handling instructions and Additional Information <br /> TSD.-SCA 79177193 E512014 CSS. <br /> ����.•Wil.��S•�.; <br /> '.24H EMERGENCY#1300"468-1760--CH/SK/TFI-Contrac�� retained by generator confersa arty autHari y <br /> 'an nitial transporter to aid or substituto additional Ir- rs g ..15. GENERATOR'S/OFFEROR'S CERTIFICATION:I herebydeclare that the contents of this consignment are full and accurate) described above b.theproper shi ing name,and are classified,packaged, <br /> 9 Y Y Y PP P 9 <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 /> F_icporter,I cek ihaf the ddntents of this consignment conform to the terns 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)(fflam a small quarfitygene(ator)Is true. <br /> G,eheralors/Offerots Printadlfyped N e e S Signatu M�onjU• Day Year. ` <br /> f6 Int0ma19naIiShipmeh. I „ . . <br /> ,. ❑In,-' (q o-U.3. • a ❑Ercport frgm U.S,..:. Popt enby/exit_ <br /> i . •.�:`fr'anspoi�ersignalu�e:�for'.hxpoits only):•. .. . ... ..` <br /> Transporter Acknowledgmentof Receipt ofkAeterials:. <br /> Nlo, •L�7�M+ n'26� !;�uNG- ,+:dw.�...>_yng;.k .F: l9 - _ .c wM •th•;: pay*—.'Year. <br /> ti. TransporterQPrinted/TypedNama / Igne a' Month Y <br /> 18.Discrepancy — <br /> . 18a.Discrepancy Indicsfion Space Quantity, ❑Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection ' <br /> Manifest Reference Number: <br /> f�. 18b.Alternate Facilif ar Generator) E U.S.EPA ID Number <br /> :J . _ .. _ --,.s+,•-. :i �� .". :-a_:. -_•,=..yRro=-.:a4:mr,.e �r�:,�c-.Q... —•t1'�.":i=��=w= '1F.t=-.m�.nsc,�x:��. "1_"'':�+,"'f�:'•'y'=.' <br /> Fadlity's Phone: <br /> F18c.SignatofedfAltematerFacillty•(orGenerator) Month 5 Day : Year <br /> z r <br /> Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> H 14 <br /> u: <br /> 120-130sigr1ok'Fad <br /> lity Owner or Opeiatce CerN9catlon of receipt of hazardous materials Covered'b the rrien�f��at kVt os npfed'IQ Item <br /> h r Pyi:-17) <br /> r Molrtti' 'DayYearFPA Forrri 870022( Prevlous 4dit�ona ark o solete; " D.�$1GryATED PACIL&TO,GENERATOR <br /> 13'14" 411'1560 .. <br /> r . . . . .. <br />