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SSL SK SHrP# 23216405e CP_3i�� ��II� ��1������ <br /> Please print or type. R? 0 7 <br /> UNIFORM HAZARDOUS 1 Generetor lD Number Form Approved.OMB No.2050 0039 <br /> WASTE MANIFEST TX 8000081205 2 Paget of 3.Eme�ellGy R�e 1,f;0 4.Manifest Tracking Ncanbe► <br /> 5,Generators Name and Mailing Addres11 s 1 1 ! 0 0 7 7 71113 SKS <br /> SAFE TY—I{LEE I SYSTEMS INC. GeneratorsSrteAddress(ifdifferentfhanmai11ingaddress) <br /> �G BDx 55; ' SAFETY—KLEEN SYSTEMS INC, <br /> SALIDAtor' CA 95368 5050 SALIDA BLVD ` <br /> Generator's Ph": 209-545-1011 <br /> 6-T . N SALIDA DA SYSTEMS INC CA 953E8 <br /> U.S.EPA ID Number <br /> 7.7ransporterz Company Name TX R000081205 <br /> U.S.EPA ID Number <br /> S.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA U.S.EPA ID Number <br /> 6-880 SMITH AVE. <br /> Faal' s Phpne: 510-795-4400 NEWARK � CA 94 560 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, eAA980$8741e <br /> HM 'and Padang Group p(any)) 14.Containers 11.Tata) 12.Unit <br /> No. Type Quantity MAV. 13,Waste Codes <br /> Fo 1 �U EDCOIALhIAZR8I30lJS WASTE, LIQUID <br /> TT G 221 <br /> W 2' p <br /> S9 <br /> 3. <br /> 4. <br /> 14.Special Handling Inshudions and Additional Inforrrrabon TSI :EVA <br /> SAL <br /> onHin iialNty.a800orte�rlto add/or7substitute additions! trans or <br /> 15. GENERATtM @RFEROR'S j6-trlt=tcartoN: I trereby declare brat the torrleMs thus y generator c r3 n f e r s agency a r1 t h fl r i y <br /> tars on neraor# b half. <br /> marked and fabeMdlPlacarded,and are in ail respects in pn)per condition for transport are fully and accurately described above by the proper stopping name,arcl are dassitiat,packaged, <br /> �r�I ecoording is applicable krtematieonaland national govemmerrtai regulations.if export shipment and I sm the Primary <br /> certify that tics concerns of this consignment ignorant conform the Of the attached EPA <br /> I oertity that the waste minirn¢ation statement identified in 40 CFR 262.27(a)Cd I am a large quantity Aclorowledgment of Consent. <br /> Generates sl0ffe s Frintsd/Typed Namgenaraior)or(b) am ti quantity generator)is true. <br /> Signature <br /> C r Month Day Year <br /> 18.International ShWwmay <br /> ElImport to U.S. ©/ ZZ <br /> ? Transporter signature(for efforts oniy): Export from U.S. Port of entrylexit <br /> W 17.Transporter of Date leaving U.S.: <br /> Receipt of Materials <br /> Transporter t Pri yped Name <br /> O .r-- Signature <br /> CL <br /> Tree 2 P Month Day Year <br /> yped Name <br /> Signature 4> ZZ U7 <br /> Morph Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type LJ Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> 18b.Alfemate Facility(or Generator) Manifest Reference Number. <br /> V U.S.EPA iD Number <br /> LL Facilitys Phone: <br /> Ld 18c.Signature ofAltemate Facility far Generator) <br /> a <br /> = Month Day Year <br /> 55 19.Hazardous Waste Report Mareganenf MOICodes(i.e.,rxfdes for hazardous waste teattuen <br /> 4 t. z t disposal,and recycling system,, <br /> 3. <br /> 4. <br /> 20.Designated FaraNty Owner or Operator.Certification of receipt of hazardousmaterials covered b <br /> ntedlFyped Name � Y the manifest except as noted In Item 1 <br /> - re Month Day Year <br /> :_PA joy8749/(qet�121T Previous editions are obsolete 2 <br /> 4`►/3 56@ DE TED FACILITY TO EPA's e. IFEST SYSTEM <br />