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SSL SK SHIP# 231218553 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Eme�rge_ncy Re�seonse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST TXR000081205 1 1—f —%8-17601007440633 SKS <br /> - <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) V VV <br /> SAFETY—RaEN SYSTEMS, INC. SAFETY-KLEEN SYSTEMS, INC. <br /> PO BOX 555 50W SALIDA BLVD <br /> SALIDA CA 95368 <br /> Generator's Phone: 209-545-1011 SAL I DA CA 95368 <br /> 6.Trans orter 1 Com any Name U.S.EPA ID Number <br /> S�FETY-{LEEN SYSTEMS INC TXR00M1205 <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 /> � <br /> SMITH AVE. <br /> 510-795-4400 'RK CA 94560 <br /> Facility's Phone: GAD98M741$ <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class,ID Number, 10.Containers It.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 0 1 NON—RCRA HAZARDOUS WASTE, LIQUID � TT �S G 221 <br /> 0 (USED OIL) <br /> Z 2. <br /> LU <br /> t9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD t ENC7 5A! CSG: <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retained by generator confers a ency authori y <br /> h0h,21 f- <br /> 15. GENERATOR'SIOFFERnn initial AOR'S CE TIFICATION: I hereby declarAdrie that tnk-he contents of this consignmaAdjtinnent are fully and accurately described above by the proper shipping name,arca 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 1 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 /> Geor's/Offeror's Printed/Typed Name Signatur Month Day Year <br /> I ',A Q —? 1 <br /> J 16.In emationa Shipme <br /> j. ❑Import to U.S. ❑Export Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> .Transporter Acknowledgment of Receipt of Materials <br /> Ti sporter 1 Printed/Typed Name Signature Month Day Year <br /> O ` Y_ <br /> Z Transporter 2 PIntoryped Name nature <br /> Month Day Year <br /> H <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space Quanti <br /> ty �, ,Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rar- Facility's Phone: <br /> C3 <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C3 1 Z -- - <br /> T <br /> 4. <br /> i <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signatike r Month Day Yea, <br /> EPA Form 8700-22(Rev.12-17) Previobs editions are obsolete. <br /> 1) 11249/156017 DESIGNATED FACILITY TO GENERATOR <br />