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SSL SK SHIP# 230654803 <br /> print <br /> 0 0 7 2 7 5 9 6 0 S K S <br /> Please <br /> P type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page of 3. me R e P 4.Manifest Tracking Number <br /> WASTE MANIFEST TXR000081205 -���- ��-���� 1007275960 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address�((if different than mailin address) <br /> SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN SYMMS, INC. <br /> PO BOX 555 5050 SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generator's Phone: 209-545-1011 SALIDA CA 95368 <br /> 6.Trthpdeter+V2RygEA SYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, INC. U.S.EPA ID Number <br /> 6000 88TH STREET <br /> SACRAMENTO , CA 95828 <br /> 916-386-4913 CA0000084517 <br /> Facility's Phone: <br /> 9a 9b.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.Nol. <br /> 1. <br /> O ;—I—.W-- Vr 13 t 31F <br /> W 2. NON—RCRA HAZARDOUS WASTE, LIQUID DM G 134 <br /> C (AQUEOUS PARTS WASHER SOLUTION) 63 <br /> p <br /> 3. NDN—RCRA HAZARDOUS WASTE LIQUID DF G 134 <br /> (AQUEOUS PARTS WASHER SOLUTION) � ( 90 <br /> 4. 1 <br /> 14.Special Handling Instructions and Additional Information TSD:SCA SAL CSG <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retained by generator confers agency authori y <br /> on initial transporter to add or substitute additional transporters on generator' s behalf. <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 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 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 /> Ge ator's/Offeror's Printed/Typq&Name Signat Month Day Year <br /> !'cT-1-V L 1(31119 1 oto <br /> J 16.International Shipments <br /> 1= ❑Import to U.S. Ex m U.S. Port of entrylexit: <br /> ? Transporter signature(for exports only). Date leaving U.S.: <br /> rY 17.Transporter Acknowledgment of Receipt of Materials <br /> ~ Tr porter 1 Prijed/Typed Nr <br /> Sig a Month I Day I Year <br /> z Transport r,22 Printed/Typed Na Signature ( Month Day Year <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space <br /> ❑ Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> v519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ 1' 2' H141 3. H141 a. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Print _,n I <br /> d Name Sign re Month Day Year <br /> 1 11 <br /> 14 <br /> EPA Form 8700-22R . -17 Previous editions are obsolete. ESIGNATED FACILITY TO EPA s e-MA IFEST SYSTEM <br /> 2) 14941/156023 3) 14941/156023 <br />