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5K SF IPP c72S59317 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> 'UNIFORM HAZARDOUS 1•Generator ID Number 2.Pae 1 of 3.Em cY nsq P one 4.Manifest Tracking Number <br /> WASTE MANIFEST CAR000039374 �� � . ;. SKS <br /> 1�� <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Esraion Premier i)r.;nd5 .Inc. <br /> t905 !-,r-heury Ave <br /> ZSCALUN CA 95320-0000 <br /> Generator's Phone: <br /> 210?-S52--6051 <br /> 6.Transporer;t Co any,Name, U.S.EPA ID Number <br /> -„ Yt�"'rPt�.�t�n 5YS1-EhS INC 'PXF:000�7 <br /> 7.Transporter 2 Company N�p U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS, !K. U.S.EPA ID Number <br /> 6000 3PrN STREET Y <br /> SACRAMENTO , CA 95826 <br /> 916-396-�19i3 CA(}00408-ir�`� <br /> Facifity's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, t0.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WINol. <br /> 1-N(3N-RCRA HAZARDOUS.!BASTE, L1,1010 <br /> o (AQUEOUS PARTS WASHER,SOLUT?ON) <br /> LU 2. <br /> w <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD, SCA 84-1 r-,101 ES_c j14 '5 CSO: 21 <br /> k,-�4H EIIERGENCY#B00--468-1760-CH/SK/TFI-Contract; retained by generator confers �99enry all'Lhori in,tial ':r•zntinrtrtPr to add or �- 1htititrrte .-ddlficln�l ran�nn�+r,rG n r ,.nmrraTr� 'c hnK f <br /> 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 labeled(placarded,and are in all respects In proper condition for transport according to applicable Intemational 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 EPAAdawxdedgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(N 1 am a large quantity generator)or(b)(V I am a small quantity generator)is true. <br /> GeneratoeslOfferoes Printed/Typed Name Signature q Month Day Year <br /> Tu/4 <br /> F 1£;international Shipments <br /> ❑Import to U.S. " ❑Export from U.S. Port of entrylexit <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> ix 17.Transporter Acknowledgment of Receipt of Materials <br /> 12 Trangporter 1 Printerd/ryped me Month Day Year <br /> a <br /> z Transporter Phnteeyped Name t Month Day Year <br /> 16.Discrepancy <br /> 16a.Discrepancy Indication Space ❑ Quantity 11Type ElResidue <br /> ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> IL Facility's Phone: <br /> W 18c.Signature of Altemale Facility(or Generator) s Month Day Year <br /> Q , <br /> z <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,iodes for hazardous waste treatment disposal,and recycling systems) <br /> 7. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of recelpt of hazardous materials covered by the manifest except as noted in Item Ise <br /> PrintedTy—pad NameL \ Slgrrre Month Day Year <br /> I- �'I 1 70 l Pr-,P.Y\rk-\ 1 'i� I <br /> EPAForin 870f)�2 v.L�V) Previous edifions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />