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BWP SK SHIP# 235119034 111111111111111111111111101111111 <br /> Please print artype. b 0 IS 0 2 9 3 8 4 5 K $ <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM MANIFEST <br /> 11-Generato,IDNumbe, ��� W81205 2.Pall of �E�4YsC! l�� 4.Ntanifast Tracking Number <br /> WASTE MANIFEST 4YsCs 1 IEs a O 8 0 2 9�89 �� <br /> 5.Genefatar's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> SAFETY—KLEEN SYSTEMS, INC. SAFETY—KLEEN SYS INC. <br /> INC. <br /> SA BOXIDA 555 5050 SALIVA BLVD <br /> SALIII6i CA 95368 <br /> Generator's Phone: 209-545-1011 SAL I DA CA 95368 <br /> 6.Tyyks a[1 CorPpUpiame SYSTEMS INC U.S.EPA ID Number T X 8000081205 <br /> 7.Transporter Company Name U.S.EPA ID Num�r <br /> 8,Designated Facillty Name and Site Address SAFETY--KLEEN OF. CALIFORNIA U.S.EPA ID Number <br /> 6880 SMITH AVE. <br /> 510-795-44 <br /> 1+NEWARK , CA 94560 <br /> Facili s Phone: th CA139$088741 8 <br /> ga• 9b-U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group Cd any)] rs <br /> 11.Tota! 12.Unit 13-Waste Codes <br /> No- Type Quantity Wt.Nol, <br /> 0 1 ETHYLENNON E GLYC+OLp��ION' (LESSDTHAN 50%) TT �' 133 <br /> W <br /> W 2 <br /> L9 <br /> 3- <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSI3VG SAL ` <br /> 24H EMERGENCY#SeO-46B--1760--CH/SK/TFI—Contract retained by generator confers agency authorit <br /> on initial transporter to add or substitute additional trans orters art ner tar' behalf, <br /> 15. GENERATORVOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are cfasMed,packaged, <br /> marked and Iabeledlplacarded,and are in ail respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I oertify that the contents of this consignment conform to the terms of the attached EPA Aclmowledgm nt of Consent <br /> I certify that the waste minimization st*rnerd identlfied in 40 CFR 282.27(a)(if i am a large quantity generator)or(b)(d I am a small quantity generator)is true. <br /> Generatar'slOff roes PrintedfTyped Name Signature Month Day Year <br /> F%J 16.lntema oral thipments <br /> 15 1 <br /> F ❑Import to U.S. <br /> = Transporter signature(for exports only), ❑E>Wori from U.S. Port of a <br /> Date leaving ng U.S.'Ut: <br /> . <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> vvG Transported PrirdedlTyped Name Signet - Month Day Year <br /> Transporfer2 PrintedTfyped Narne � <br /> Signature Month Day Year <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residua ❑partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.NRemate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> CJ <br /> li Facility's Phone <br /> LL, 18c-Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> x <br /> W19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. H141 2. 3. 4. <br /> 20.Designated Facility Owner or Operator!Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Sa <br /> Prnted Name Signature Month Day Year <br /> EPAFpr� <br /> 2-17) Previous editions are obsolete. IGNATEO FACILITY TO EPA's e-MANIFEST SYSTEM <br />