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SSL 9K SHIP# 232888655 IIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIII <br /> Please print or type. O O Form ppro ed0OMB No 2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Pa 1 of E r cy se P o 4.Manifest Tracking Number <br /> WASTE MANIFEST CAROO0039370 .` 8�-��` "1�8b 007706330 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Escalon Premier I.lrands Inc. <br /> 1905 Mchenry Ave <br /> ESCALON CA 95320-0000 <br /> Generators Phone: 209-552--6051 <br /> 6,g1Xns�p�tJr VLaafy&eSYSTEMS INC U.S.EPA ID Number TXROOOOB120S <br /> 7.Transporter Company Name 1 1 U.S.EPA IDNumhe <br /> 3 <br /> .S 6 9 20 <br /> E <br /> B.Designated Facility Name and Site Address SAFETY—KLEckxq1N SYSTEMS. INC. U.S EPA ID s <br /> IIDm <br /> DNuber <br /> 6000 88TH STREET <br /> SACRAMENTO CA ?5828 <br /> 916-386-4913 CAO000O84517 <br /> Facility's Phone'. <br /> 9a 91h.U.S.DOT Description(including Proper Shipping Name,Haunt Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt'Nol. <br /> 1NON-RCRA HAZARDOUS WASTE, LIQUID G 134 <br /> o (AQUEOUS PARTS WASHER SOLUTION) <br /> R W T <br /> z 2. <br /> W <br /> 0 <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD: SCA 84781075 ES12014 202050 CSG: 21 <br /> 24H EMERGENCY#800-468-176O-CH/SK/TFI-Contract retained by genera4:or confers agency authorit <br /> an initial transporter to add or substitute additional trans orters on enera9or 's behalf. <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the Draper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulators.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 EPA Acknowledgment 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)(ff I am a small quantity generator)is tore. <br /> Generators/Offerors Print yped Name Signature Month Day �7Year <br /> 16.International Shipments - <br /> Import toUS. ❑Export from US. Port of endylexit <br /> ? Transporter signature(for exports only): Date leaving U.S.'. <br /> K 17.Transporter Acknowledgment of Receipt of Materials <br /> Trans rt 1 PnmtedlType Name Signature Month Day Year <br /> O <br /> a <br /> = Trans 2 PnntedlTyped Name Signature Month Day Vear <br /> 1 <br /> l r/17 Cv� �l i'2Ctf-q /-2 // p <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ty Type Residue 1 <br /> ❑ Quanti ❑ El Rejection Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 H141 2. a 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 /> 1 Pri d e Si a Monti Day Year <br /> 110 76410!1egvNt-17) Previous editions are obsolehl I FACILITY TO EPA's e-MANIFEST SYSTEM <br />