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91111- K SHIP# R2'.933811.Tij.'TI Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number SKS WASTE MANIFEST 12 Vf�V 10- 071,900417 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) 23tacktan Rubber Mfg Go Inc, OP3 N F 1 n cKI Rd UNDEN CA 95-236-9455 Generator's Phone: P09-88 -"1172 o.Transporter 1 Corr�pany,IN me ,- #,{ U.S.EPA ID Number S FE'T�`'.'t4E.F'E SYSTEMS i G:MS 1W. T X€5;00 81 x'05 7.Transporter 2 Company Name U.S.EPA ID Number CLEAN HARBORS CEIV) SIA-1 INC. 'MmO39--i22-ew 8.Designated Facility Name and Site Address CLEAN i-ARPORS ENV I f{Il��,N' N f A . ZEERV I C S !N U.S.EPA ID Number 2247 i HIGHWAY AY 7 a. � Facility's Phone: KIMBALL NE C-94145 NED%172:351% 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity wt./Vol. 1' NA3082, HAZARDOUS WASTE, LICUID D008 leis 223 Vit.O.S., 'LEAD, BENZENE), 9, PG 111 Q Of W Z Z LU u 3. 4. 14.Special Handling Instructions and Additional Information TSD 4 KP 1 Fw,�,,,;Ft S 1 2"9t"06 CEO: r4H EMERGtNCY`#>�00--468--17F,O--- H/C-ZK!'�'F'I-Corit-o,:ir..t ret-afrt,ed by yerienator comfersi Z+ envy atttbar°:ii v Q initis . 8n porter add Or hSt't,rs p R �0 �.a - •fi g A .. -., 15. GENERATOR'SIOFFEROR'S 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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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. Generato)',s!Q. roe,Printed/Typed Name j Signature : Month Day Year 16.International Shipments F- ❑Import to U.S. ❑Export from'U.S, Port of entrylexit: z Transporter signature(for exports only): Date leaving U.S.: tY 17.Transporter Acknowledgment of Receipt of Materials LU a Tran¢ er 1 Printed/Typed Name Signature Month Day Year Transporter 2 Pdhpd/Typed Name Signature ! Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ Cd LL Facility's Phone: rpriurn 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z rn19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal and recycling systems) ® 1. 2. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous me rials cover them nife xcep It 18a PdritedlTyped Name n Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY 117f4E2907/a� `d;, :L,f4.