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SK 4111P# 2a974360a" <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Ph e. 4,Manifest Tracking Nuumber <br /> WASTE MANIFEST d I 1007313167 sKS5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> RO Lfib Rubber CO. Inc. <br /> 81330 W Li nrte Rd <br /> Generator's Phone: -8-36-0965 <br /> 6.Transporter.1;Company Name vS.EPA ID Number k,�` <br /> SYSTEMS INCI NC� � #.P,,a z j010, <br /> , <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address L"LEAN HARBORS SAN JL'ibil U.S.EPA ID Number <br /> 1 22 ERRYESSA ROAD <br /> SAN .ORE: CA 95133 <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> and Packing Group(if any)) 13.Waste Codes <br /> HM No. Type Quantity Wt.Nol. <br /> P <br /> W <br /> z 2. 1KNE- NOIr+-(�� RCRAt �d��`5t.`�,:Ab�k�DO I£= S01-IDS :�, P 181 <br /> y i,3r" ""� �..r..I,..„ DRUM), "1.WASTE, -- ---. <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TET S J 81 4(4,0 3fi i3 RCq 1 754�.9 CSIG4, <br /> 24H netain ed 'by getier,t or r,`.t.61l1'er s agency <br /> 4'r- j-11i iraI. t>r ns .£)1^ter to a0old or sub--;-t m to atjCji"ju.LCnal L'r ai-is1.3Y'tEt s oyrt <br /> 15. GENERATOR'S/OFFERORS CERTIFICATION: I 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 labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I 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 /> Generator's/Offerors Printed/Typed Name Signature Month Day Year <br /> s• <br /> 16.International Shipmentsi <br /> I- ❑Import to U.S. ❑Export from U.S. t Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W- 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> 11-- TFariffporter 1 Printed/Typed Name - SignatureN Month Day Year <br /> r <br /> d i, �; �.�. ..�^ ,ms' `.;l' � �,rr�✓.. tet' �f`:- � `'f, �r�� <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> 9 <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity 1:1 Type El Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 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 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev 12-17) Previous editions are 000le�e GENERATOR'S INITIAL COPY <br />