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SSL SK SHIP# 2231840355 ?�314�;- 0 1111111111111111111111 <br /> Please print or type. a07440423sKsForm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3. me�gg�x��yy Rgs se Ph 4.Mantfest Tracking Number <br /> WASTE MANIFEST T X 80062181205 1 —tf1�iD-yf l " 1 Fg0 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> SAFETY—KLEEN SYSTEMS, INC. SAFETY--KLEEN SYSTEMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generators Phone: 209-545-1011 SALIDA CA 95368 <br /> 6-Trans FIETY VILENEN SYSTEMS INC U.S.EPA ID Number <br /> 11��,, T X 800008#c 05 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA U.S.EPA ID Number <br /> 68a0 SMITH AVE. <br /> NEWARK , CFI 94560 <br /> CAD980887418 <br /> 510-795-4400 <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)) t No. Type Quantity WtNni13.Waste Codes <br /> 0 1' NON RCRA HAZARDOUS WASTE,LIQUID TT G 133 . <br /> 0 ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) <br /> w <br /> O <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:EVG SAL CSG: <br /> 24H EMERGENCY#800-468-1760--CH/SK/TIrI—Contract retained by generator confersa enemy authori y <br /> Y <br /> 15. GENERATOR'5l4FFEROR'SCERTIFICATION: (hereby declare that the contents of this consignment are sully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are to all respects in proper condition for transport according to applicable intamalional and national govern ental 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 th t the waste minimization statement identified in 40 CFR 262.27(a)(if i am a large quantity gener ilor)or(b)(if I e a s ua generator)is true. <br /> Generator's( roes PnntedlTyped NI( Signature , Month Day Year <br /> 16, nma di <br /> efio rpmen E]Import to U.S. z <br /> ❑Export from U.S. Porttrylexit: <br /> Transporter signature(for exports oniy): Dat ng U.S <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporte�Pnntedrryped <br /> Signature Month Day Year <br /> 0. <br /> Omi ---vi ry0 <br /> eSignature 0� dear <br /> 9 Month Day Year <br /> 18.Discrepancy I�I <br /> 18a.Discrepancy Indication Space n Quantity !�I � I—I Residue Partial Ro don t I T I I I ( �Full Rejection <br /> 18b.Altemate Facility(or Generator) Manifest Reference Number: <br /> 1 <br /> U.S.EPA ID Number <br /> V <br /> LL Facility's Phone: <br /> W 18x.Signature of Alternate Facility or Generator) Month Day Year <br /> a <br /> a <br /> 19.hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU O 1' 2• r3. <br /> 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 /> PrintedlTyped Name 4p ySignature Month Day Year <br /> EPA Form 8700-22 Rev.12-17) Previous editions are obsolete. <br /> 1)651115030 E NATED FACILITY TO EPA's a-N! NIFEST SYSTEM <br />