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Please print or type. Farm Approved.OMB 10.2050-0039 <br /> UNIFORM HAZARDOUS t Generator ID Number ;x � Q: 2.Pape 1 of 3•Errcysjnsp�RF�r�a 4. a <br /> WASTE MANIFEST 1 33 v�q 14Q � 49 9 AS <br /> 5,Generator's Name and Mailing address Generators Site Address{rf different than mailing address <br /> SAFE i'Y-KLEEN SYSTEMS, IN . 5�=E rY-�tL.E1~N SYSTEMS, f C. <br /> PI] BOX 555 5150 SALIDA BLVD <br /> SAL I DA CA 95368 <br /> Gsnee�ropators Phone: fD — i L I)A <br /> fi.9N&4-9w&4eSSy TE INC U-S.EPA ID Numl <br /> T X Reelfts j a65 <br /> 7.Transporter 2 Company Name U.S.EPA ID Nu <br /> mber <br /> 8.Dss0ated Fadlity Name and Site Address SAI';ETY--KLEEN( OF CAL I FrJRNI,4 U.S.EPA ID Number <br /> 68M SMITH AVE. <br /> 51LI-795=-4400 NEWARK , CA 9456@FaoR Phone: CA09al@687418 <br /> 9a, 9b,U.S.OOTDesrxiption{including Proper Shipping Name,Hazard Class,tD Number, gp•Contai ' <br /> HM and Packing Group(d any)} 11.Total .11.Unit 13,Waste C <br /> No. <br /> 1Type Quantity Hol, <br /> mk RM HAZARI?M WASTE,LIQUID TT:. <br /> .. .. .. _.. .. 133 <br /> ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) (,D I I�o <br /> z 2, <br /> w <br /> ca <br /> 3. <br /> 4. <br /> 44-.SpeciatHaiW4Ntehve§errs•and Additional k4ormatien TID,. <br /> Eve <br /> Oft- 2+4H.. �1��1�Y�@-�8-1768-�1tSH1'#'f � rr�a�is�rd iay �lrr>rerat�er rarif �. ����y. <br /> initial trans <br /> porter to add.ar % di <br /> ute additional trans ert: an a Era �r�a beIf. <br /> I& GENERATOR'SIOFFEROR'S CERTIFPCATIOH:'I here0ydeclamthaMe contents of thls cunei <br /> gnment ars My arid acaratefy desdibed above-by the.proper sh flarhe.ami are cAglseilted,,pat cago <br /> marked and laheladlplacerded,and are in all able , <br /> respects m; proper ca W60n for transport according to appllointernational national govemmm W regulations.If.mPP4 shipment and I am the pit <br /> viry <br /> Exporter,l eer*that Itie contents Of tits consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> 1 m*that the waste minimization slatentent identified in 40 CFR 227{a}{rf i am a forge quardity generator)or(b)(if I am a small quanlRy generator]is true, <br /> Generator's209Name <br /> me <br /> ee <br /> 18.Intemafonal Shipments Fe x <br /> ❑.IWrt to U.S. ❑Ewart ffom U.S. Part of entrylexit <br /> ? Tranaportersignature[for exports only]: Date leaving U.S.LU <br /> : <br /> Is <br /> Transporter I Printedrlyped NameMonth nacre <br /> i. ... <br /> Year <br /> T... .sporter 2.Pr ntedlTyped Name. ..... Si9 ..........:.. .. . ....... ... ........... .........................-...*.. .. ....-..... .. ...... <br /> �. <br />......- ...... . .-..... . .......... . . Iktotl�l Year .... <br /> I <br /> "18,Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity ❑Type ❑Residue ❑Parliat Rejection <br /> ❑Fun Re) on <br /> 18b-Alternate FacilityManifest Refewce Number. <br /> {or Generator) U-S.EPA ID Number <br /> 'J <br /> i.7 <br /> ri FaciihYs Phone: <br /> W 18c-Signature of ARemate Facility(or Generator) Month ' DEY Year <br /> a <br /> z <br /> 55 19.Hazardous Waste Report Management Method Codes{i.e codes for hazardous waste treatment,disposal,and rec)d ng systems) <br /> 7— <br /> M141 Z. 3. <br /> 4. <br /> 20.Designated Faality Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrinledlTyped Name Signature <br /> Alvnlh Oay ear <br /> L'rL <br /> EI}F 8T01 ( k.12-17} Previous editions are obsolete. 1 <br /> i'1 DESIGNATED FACILITYTd GENE TOR <br />