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2,1115 0 cv� <br /> SSL 5K SHIPN °"o'^�� �' <br /> Please print or type. 0 0 7 4 0 0 9 2 4 3 K S <br /> 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS CAR000039370 2.Page 1 of 3 E Re n o 4.Man�'(e t�T4in�Njpnp�r <br /> WASTE MANIFEST 1 j �6P 9�� �� O o 7/I f'0 9 2 /I SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Morass(if different than maging address) V V J �'I' 1�\7 <br /> Escalon Premier Brands Inc. <br /> 1905 Mchenry Ave <br /> ESCALOM CA 95320-0000 <br /> Generators Phone 209—SS2--6051 <br /> 6.N MC EtWeSYS1'EMS INC U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 2 Company Na U.S.EPA ID Number <br /> r7 7 <br /> B.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, INC. LFS.EPA ID Number O' <br /> 5000 98TH STREET <br /> 916-386-+4913 SACRAMENTO CA 55828 <br /> Faolity's Phone: CA00000245'17 <br /> Ra. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 0.Containers <br /> HM and Packing Group('d any)) 11.Total 12.Unit <br /> No. Type Quantity Wt.Ne. 13.Waste Codes <br /> 1NON-RCRA HAZARDOUS WASTE, LIQUID G <br /> o (AQUEOUS PARTS WASHER SOLUTION) 134 <br /> z 2. <br /> W <br /> t7 <br /> 3. <br /> 4. <br /> 14,3pedNlHandlingmstrucdonsandAdditional Intonation TSD:SCA 82647058 ES12014 202014 <br /> on"iniltRialNtran porterlto0add,or/substitutecadditiona ttransporterrs onconfers <br /> genera'tor 's uerialfil <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment arefully and a tely described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeled/placarded,and are in all respects in proper condition far transport according to applicable intemation 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 Can nt. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(gl am a small quantity generator)is true. <br /> GeneretursrOgeroes Printed!! Name Signa Month Day r <br /> e S b(o ap <br /> � 16.Infematlonal Shipments r <br /> 2Import to US. LJExport from U.S. Port of entry/ent: <br /> Transporter signature(for exports only): to leaving U.S.: ' <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> C T reporter 1 PrinName Signa <br /> p fat, x-r Month Day Yaer <br /> W Tran sporter PrPririnntt`ed/Typed NameY`� aNre f O Y <br /> Yiliar <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑TYPs ; <br /> Residue ❑ParAal Rejection El Full Rejection <br /> 18b,Alternate Facility,(or Generator) Manifest Roffierence Number: , <br /> :3 U.S.EPA ID Number <br /> U <br /> LL Facility's Phone: r <br /> W 18c.Signature wmmrnaie Faality(or(3enerator) <br /> Q Month Day Yeer <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> c 1' <br /> H141 z. 3. <br /> 4 <br /> WDe-signated cility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in I em 18a <br /> e 1 r�J l Lv�7i // Monty DaYbvOJJ7) Previouseditionsareobsolete. <br /> DESIGNATED F ILI OEPA'se•MANIFESTSYSTEM <br />