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i <br /> r Please print or type. Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1•Generator ID Number � �,-�2.Pag 1 of 3 Em _ ss 4.ManilestTracking Number <br />! WASTE MANIFEST T X RE�$$$91 cf�5 �� � � (�V��V <br /> d V V <br /> j <br /> S.Generators Name and Mailing Address �- GeneratPPr s Site Address(if different than 1007984383 <br /> O 7mailing address} <br /> f SAF ET Y-KL E EN SYSI EMS, INC, SAFETY-f(L.E.E:N SYS1 EJIS INC. <br /> PCBOX 555 5053 SRI-IDA BLVD ' <br /> SAL I L4� Cis X5368 <br /> Generator's Phone: �0 -545 L 1 1 SAL I DA CA 95366 <br />! 6-Tgry�pode i Camp �y 1�lame SYSI.E-MS INC U.S.EPA ID Number <br /> `]Fsf-t V rt tkP} TxR��Q0a1��1` <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8-Designated Facility Name and Site Address SAS=E T Y"KLEEN OF CALIFORNIA U.S.EPA ID Number <br /> 6890 SMITH AVE. <br /> NEWARK CA 94560 <br /> CAD980887416 <br /> 510-795--44& <br /> Facility's Phone: <br /> ga 9b.U.5.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 1t.Total 12.Unit <br /> HM and Packing Group(if any)] 13.Waste Codes <br /> No. Type QuantityM./Vol. <br /> 1. NGN-t CRQ f4AZARDOUS WASTE, LIQUID T i G 221 <br /> o e.LIE COIL -- <br /> Z 2. <br /> LU <br /> 3- <br /> 4.4. <br /> 14.Special Handling Instructions and Additional Information T5D r EUG SAL CSG <br /> i <br /> E+4H EMERGEtICY*800-469-1760-CHiSK �FI_CQntract retained try generatp3 confers a esu+=y authority <br /> 3n initial transporter to add ar �Ubstitute additional tr ns rters on nera tar' s behalf. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 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 iabeledlpiararded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am Bre 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 yste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I a yb small q tity generator)is true- <br /> Generator'slOfferor's -ntedffyped Name Signature Month Day Year <br /> • �� ►7 Z- <br /> 18.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit: _- <br /> ? Transporter signature(for exports only): Date leaving U-S-: j <br /> W 17.Transporter ledgmenf of Receipt of Materials <br /> r— Transporter 1 Pr yped Name Signature <br /> Q ��/r 9 � Month fD'ay] Year j <br /> 0. ', r t" 1 I <br /> W Transporter 2 Printedrfyped Name Signature r Month Day Year <br /> I <br /> 18.Discrepancy <br /> 1 Be-Discrepancy Indication Space ❑Residue ❑Partial Rejection ❑Full R ' <br /> Quantity Type )aC' Rejection <br /> Manifest Reference Number: <br /> 18b-Alternate Facility for Generator) U.S.EPA ID Number <br /> U t <br /> LL Facility's Phone: I <br /> Q18c-Signature of Aftemate Facility(or Generator) Month Day Year <br /> y19.Hazardous Waste Report Management Method Codes(i-e-,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1 H@39 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 18e 1 <br /> PdnttpdVyped Name Signat ` Month Day Year I <br /> 8700 <br /> EP�.Fqr� 0y-2��y(� 12-1]) Previous editions are obsolete. - DESIGNATED FACILITY COPY <br /> 1� YD[l f�I!I1 ED THIS MANIFEST,YOU HAVE RESPONSIBILITIES UNDER THE e-MANIFEST ACT.SEE INSTRUCTIONS ON REVERSE SIDE. <br /> 1 <br />