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2'Z-7'7 6 0-W 63 <br /> J <br /> SSL SK SH IR# <br /> Please print or type. N0qO —'3 Fonn Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS 1.Generator ID Nu(nber 2.Page 1 of 3. me Res e P 4.Manifest TreekNum <br /> WASTE MANIFEST <br /> CAL000375509 - �-4� 10069't2§14 SKS <br /> 5,Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> RO Lab Rubber Co. Inc. <br /> 8830 W Linne Rd <br /> TRACY Chi 95364-9109 <br /> Generator's Phone 209-836-0965 <br /> 6.Tr �lc�trt ny� <br /> SYSTEMS INC U.S.EPA ID Number <br /> TxR0eM1205 <br /> 7.Transporter 2 Company Name U.S-EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> 8.Designated Faality Name and Site Address CLEAN HARBORS ENVIRONMENTAL SERVICES, IN U.S.EPA ID Number <br /> 2247 S HIGHWAY 71 <br /> KIMBALL , NE 69145 <br /> NED981723513 <br /> 308-235-4012 <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class,ID Number, 10.Containers 11_Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if ani No. Type Quantity Wt./Val. <br /> 1 -�NE1NE� NON RCRA HAZARDOUS WASTE SOLIDS, 1 0 DM 2-q DO P 223 <br /> o (ABS RBENTS CONTAMINATED WITH OIL),--KfA-n. <br /> a <br /> w <br /> 1� 2. <br /> W <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:KP 790830?- 8015429 CSG <br /> 224H EMERGENCY*800-468-1760—CH/SK/TFI—Contract retained by generator confers agency authori y <br /> on initial transporter tq Add or substitute additional transpartors an u2nerator' s behalf <br /> 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, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemalional 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 EPAAckncwledgmert of Consenl- <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 /> Generators/Offerors Pdnledrryped Name Signature Month Day Year <br /> J 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.5Port of entrylexit: <br /> 9 Transporter signature(for exports only) Date leaving U.S-: <br /> W 17.Transporter Ackrlowledgmenl of Receipt of Matedals <br /> O Transporter 1 Pr nledfTypod Name s't 1 r Signature Month Day Year <br /> `F f t�V .d 6 Z.-ili <br /> N 2 Primped Name Si <br /> �Y L-- <br /> �M M � � Month Day Year <br /> t—' z 7 2— 1 7 <br /> 18.Discrepancy <br /> IBe Discrepancy Indication Space ❑ Ouantity ❑Type ❑Residue ElPartial Rejection ElFull Rejection <br /> 18b.Altemate Facility(or Generator) Manifest Reference Number: <br /> U-S.FPA ID Number <br /> V <br /> Facility's Phone: <br /> LU <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> i <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4 <br /> 20.Desi nate,Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> PrinleOyped Name Signature Monthtr--i) w UL) MOF <br /> EPA Form 870022Rev.12-17-)- r iousediiions are obsoete. <br /> 1)8538003/17 2 DESIGNATED FACILITY TO GENERATOR <br /> 8029 <br />' S. <br />