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SSL 5K SHIP# 228448S47 IIIIIIII III INI�NBIIIIHIIIll I <br /> 007070157SKS <br /> Please pont or type. Form Approved,OMB No.2050-0039 <br /> Pa <br /> 1.Generator ID Number . g 1 of 3 y se ho <br /> UNIFORM HAZARDOUS CAR000039370 21E' �'" + -" ( `) d.Manifest Tracking Nur <br /> 1007070157WASTE MANIFEST SKS <br /> 5.Generators Name and Mailing Address. Generators Site Address(Adherent than mailing address) <br /> Escalon Premier Brands Inc. <br /> 190S Mchenry Ave <br /> ESCALON CA 95320-0000 <br /> Generators I('-SM <br /> 209-S52--6051y <br /> 7 <br /> 6. b�FI(OoMMe SYSTEMS INC U.S.EPA ID Number ,ti_ <br /> 7.Transporter 2 Compeny Name53 ^ S mtt ID Number <br /> 8../Designattee`d`L`FaaTcil^ity Nlame and Site Address `SAFETY—KLEEN SYSTEMS• INC. U.S.EPA II0r <br /> D Number <br /> 6000 88TH STREET <br /> SACRAMENTO CA 91��82 <br /> CA0000084� <br /> 916-386-4913 F i"' <br /> Facility's Phone: <br /> gra 91b.U.S.DOT Description(including Preper Shipping Name,Hazard Class,ID Number, .Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> o. Type Quantity Wt.Nol. <br /> 1 NON-RCRA HAZARDOUS WASTE, LIQUID G 134 <br /> 0 (AQUEOUS FARTS; WASHER SOLUTION) A <br /> 0S DO, t5p <br /> z 2 <br /> W <br /> f7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD: SCA 80037441 E 12014 201923 CSG: 21 <br /> �1l7aSoa � 57,�� <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract retaine I by lenera9;or confers aggenvy authorir- <br /> on initial transporter to add or substitute additions trans orters on ever 't.or 's e. , `, <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and scot stely described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabelecloacarded,and are in all respects in proper condition for transport according to applicable internation 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 EPAAcknewledgment of Con ant. <br /> I certify,that the waste minimisation statement identified in 40 CFR 262.27(a)(if I am a large quantity genera or(b)(dl m a small quantity generator)is true. <br /> GeneatoeslOgemr PdntedRyped Nae Signal Month Day Year <br /> Mme/ '11 09 C]S <br /> J 16.International Shipments ` <br /> F <br /> 1:1 Import to U.S. El Export fromU on of entry/exit: <br /> ? <br /> Transporter signature(for exports only): ate leaving U.S.: <br /> W 17.TansporterAcknowledgmerd of Receipt of Materials <br /> LJ <br /> Ta r 1 Pon Ryped yeme Si Month Day Year <br /> a cc,; oto b <br /> = Tramucorter 2 Pdntedrryped NameMny�oDa 'Y r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space n <br /> ❑ Quantity ❑Type El Rel tie ❑Partial Rejection El Full Rejection <br /> r <br /> Manifest eference Number: <br /> 181b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> < Facility's Phone: <br /> I Bo Signature of Alternate Facility(or Generator) Month Day Year ' <br /> Q <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes(i.e,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. H141 2. 3. a. <br /> 1 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noned in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EP Fprr��gg70p-pp22 ev.1A-1 7) Previous editions are obsolete. <br /> 1� gY41/1,603 DESIGNATED FACILITY TO EPA's . ANIFEST SYS EM <br />