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SSL- SK SHIP# 231492653 IIIIIII111111111111NI1111111111111 <br /> 0 0 7 6 6 9 9 3 7 S K $ <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Em R se b9M. 0.Manifest Tracking Number 766993 �� <br /> CAR000039370 Y. ����� f al.; <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generators Site Address(8 different than mailing address) <br /> Escalon Premier Psrands Inc. <br /> 190S Mchenry Ave <br /> ESCALON CA 95320-0000 <br /> Generator's Phone. 209-552^6051 <br /> fi T <br /> ����ylo U.S.EPA ID Number <br /> SYSTEMS INC7i(r<U 'i` <br /> 7.Transpori Company Name U.S.EPA ID Number <br /> ce�py) b21 <br /> 8.Designated Facility Name and Site Address SAFET'r-KLEEN SYSTEMS, INC. U.S.EPA ID Number <br /> 6000 S8TH STREET <br /> SACRAMENTO CA 95828 <br /> 916-386-4913 <br /> Facility's Phone'. <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt No. <br /> 1 NON-RCRA HAZARDOUS WASTE, LIQUID G 134 <br /> o (AQUEOUS PARTS WASHER SOLUTION) <br /> 04 ` $o <br /> Z2 i <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD: SCA 83282050 ES 1201.4 202024 C; u: '1 <br /> G1 CUZ(Q22. . <br /> 24H EMERGENCYk800--468-1760-CH/SK/TFI-Contract retain¢d by genera4;nr confers a envy e1.1 . •..Y:.I ..1 <br /> on initial tran lrter to add or substitute addition °''" <br /> 15. 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 Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations,N export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the tens of the attached EPAAcknowledgment 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 /> GeneratorstOBerors Pn rryped Name Signature Month Day Year <br /> 4t. It-3 acj <br /> J 16.International Shipments _ <br /> T— ❑Import to U.S. Export from U.S. Port leaving U.S <br /> ? Transporter signature(for exports only). Date leaving U.S.: <br /> K17.Transporter Acknowledgment of Receipt of Materials <br /> w Month Day Year <br /> T` sportier 1 Plrintedrry ame Signa <br /> a pit <br /> Q Transer Printed/Typed Name nature Month Day Year <br /> port <br /> K t I <br /> 1- ✓ i <br /> I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ElQuantity ❑Type ❑Residue El Residue Rejection El Full Rejection <br /> Mandest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Ph..'. <br /> w 18c.Signature ofABemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 11141 2 3. 4 <br /> 20.Designated Facility Owner or Operator:Cenificabon of receipt of hazardous materials mvered by the manifest except as noted in Item 18a <br /> lPnn me Signature Month Day Year <br /> EPA Form 8700-22(R f2-17) Previous editions are obs e. SIG ED FACILITY TO EPA's e•MANIFEST SYSTEM <br /> 11:14941/156023 <br />