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1314p, SY, SHIP# 235A18785 II 11111110111111111111111 <br /> Please print or type. 4 8 8 1 1 6 5 3 Q $ K S <br /> 1.Gerieretor ID Number12,PagelofForth Approved.OMR No,2t?5i1-0039 <br /> UNIFURIA FIAPARppL13 3.E envy Response Phone 4 Manifest h eking Number Q <br /> WASTE MANIFEST r X I?400sU$1205 1 1—t3i�i�-4�fJ-1760 SKS <br /> �v V <br /> 5.Generators Name and Mailing Address Generator's SHe Address[if ditwt than me6ing address) S n <br /> SAFETY—KLEEN SYSTEMS, INC. SAFETY—MLEEN SYSTEMS, INC. <br /> PC BOX 555 5050 SALIDA BLVD <br /> SAL.IDA CA 95368 <br /> Generator's Phone: 209-545-1011 1 SAL I DA CA 5535 <br /> 6.Transporter 1 Company . .Name U.S.EPA ID Nu r <br /> SAFETY—KLEEN SYSTEMS INC TXR00100 1205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Nuri ber <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA U.S.EPA 0 Nun bar <br /> 5990 SMITH AVE. <br /> NEWARK , CA 94560 <br /> Facilitya Phone: 5117--795-4400 CAD9806$ 41 B <br /> ga, 9b.U.S.DOT Desariptfon{including Proper Shipping Name,Hazard Class,ID Number, 10,Cur" era 11,Total Unit <br /> HM and Packing Group(if any}} No. TYR Quantity tivd, 13.Waste Tolles. <br /> NON--RCRA HAZARDOUS WASTE, LIQUID TT221 <br /> (USED OIL) <br /> 2. <br /> w <br /> t� <br /> 3- <br /> 14. <br /> 14,Special Handling Instruetkns and Additional Information T 531: VG <br /> SAL CSC, <br /> 24H EMERGENCY#600-468-1760—CH/SKITFI—Contract retained by generator cnrrf rs aenvy a 'thorit <br /> 15. GENFlZ4TOR SfDFFEROR'S C.RTIFIGATION:I hereby declare that the contents of this coni nmeni are fully and accurately d above by the proper sN name,and are classified, ed, <br /> marked and labeWplacarded,and are in all respects in proper conidition for transport according to applicable international and na 9ovem I regulations.H shipment and I am the •maty <br /> Exporter,I OR*that the oortents of this ocnai nmem conform to the terms of the attached EPA AcknowWOgment of Consent. <br /> I cerMy that waste minimization statement Identified in 40 CFR 262,27(a)(if I am a large quantity generalor)or(b)(itI am a s qua orator)is true. <br /> GenerawslDiFe s PrintedlTyped Signature Month Year <br /> J 16.Intermffiftntal SFIPmWf <br /> F ❑Import to U.S. ❑Export from U.S. Po try/ext <br /> Transporter signature(for exports only): U.S.: <br /> rY 17.Transporter AdmalladIgment of ReceJpt of Materials <br /> CETransporter 9 Prin yped Name Signature Month D y Year <br /> o r <br /> a <br /> z T n yped Name <br /> Signature Month D y Year <br /> 18.Discrepancy <br /> 18a.Discrepantly Irl t ton Space ❑ Quantfty ❑Type ❑Residue ❑Partial Raj.%, ❑Full R led., <br /> rdfest <br /> 18b.Alternate Facility(or Generator) MaReference Number. U.S.EPA fD N <br /> J <br /> U <br /> W Fadity's Phone: <br /> W I Be.Signature of Alternate Facility(or Generstoo Month Day Year <br /> a <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes[.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 1 �t`03 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Cerdfrcadon of receipt of hazardous materials cowered by the manifest except as n owd in Hem 18a <br /> PrnM Narver gnature• Month Day Year <br /> EPA Form 87(YD-22(Rev,12-17) Previous editions are obsolete. SIGN ITY TO PA's e-MANIFESTSYSTEM <br /> } 11c4�?!15ia1B17 <br />