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SSL SW SHIP# 23417 5336 II�IIII�IIIIIIII��II�I�)II IIII(I�I III <br /> 0 0 7 9 4 5 8 7 7 S K S <br /> Please print or type. I Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 039377—la? <br /> 1 of a.Erpg^.@ncy 9e ns F onP,1 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> A "`' -�� `" 007948877 SKS <br /> 5.Generators Name and NiMAddress Generators Si Address(if different than mailing address) <br /> Esc alon Premier l+rands Inc. <br /> 1905 Mchenry Ave <br /> ESCALON CA 9S320-0,'00 <br /> Generator's Phone: 209-5S2-- ,0S1 <br /> 6.ggrorW.r.t ,VeapyLVeaY�i.F IS 1N� U.S.EPA ID Number T 4001y81.205 <br /> 7.Transporter 2 CompaRykjame I U.S.EPA ID Number <br /> GLLS �t� �C�IJr IJG / �- YI/l 039�2c 5' <br /> 8.Designated Facility Name and Site Address $AFE;TY—KL.EEN SYSTEN,6i INC. U.S.EPA ID Number <br /> 6000 88TH STREET <br /> SACRAMENTO i'�A `�?5E12O <br /> 91.6-386-4913 CA0000084517 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. x� Quantity Wt.Nol. <br /> 1 NON—RCRA HAZARDOUS WASTE, LIQUID 0 134 <br /> 0 (AQUEOUS r'ART5 WASHER SOLUTION) � ,,(n <br /> w <br /> W <br /> Z 2. <br /> w <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Information TSO: ra'CA 7-'1 R F1,476 E512014 202121 CSti:21 <br /> 24H EMERGENCY#800--468-1760—CH7SK/TE7-•Contr,,ict retain d by genera�t:or confers a ency auttlof'i <br /> on 'ni•tial 1rafPsw�''` i.er to add or subs�ti�tut� addi't.ion :i. trans ar�r�r- on enera�or '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 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 international 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 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)(if I am a small quantity generator)is true. <br /> Ytor's/Offeror's Printed/Typed Name Si re Month Day Year <br /> IU' rJ r. r J. �... —' Z <br /> —1 16.I ternational Shipments <br /> I— Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> IX 17.Transporter Acknowledgment of Receipt of Materials <br /> T 1 14- At�) <br /> 4kner2 <br /> rtPinted/Typed Name ature Month Jay Year <br /> n <br /> j ?-� <br /> nt�dlTyp� Si Month Da Year <br /> 18.Discrepancy <br /> 1 'sc e ncy IndicationSiaftOuantit <br /> 1 A rV /eYr�./h� y Type sat K ,�y� �(�1 Residue Partial Rejection ❑Full Rejection <br /> C r< 1 aH ' —I�faniflst RCference Number: b`N <br /> 186.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> v <br /> LL Facility's Phone: <br /> w 18c.Signature ofAltemate Facility(or Generator) <br /> Q Month Day Year <br /> z <br /> tLI <br /> 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI <br /> 1. 2. 3 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 /> ed Nam 1 Month Day Year <br /> EPA For 8700-22�(R v. P_t7) Previous editions are obsolete. ftSi FACILITY TO EPA's e-MANIFEST SYSTEM <br />