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SSL SK SHIP# leE86*68l 00696a267SKS <br /> Z'Z*S 'r7110 �� 6©� 3! Form Approved.OMB No.2050-0039 <br /> Please print or type. 4.Manifest Tracking Number <br /> 1.Generator ID Number 2.Page of 3.Emer enc Re ponse Pho e 9 �■�� <br /> UNIFORM HAZARDOUS CAL600375509 '" $ —X68--1 � K <br /> WASTE MANIFEST lJ <br /> 5.Generator's 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 GA 95304-9109 <br /> Generators Phone: 209-836-0965 <br /> V U.S,FPA ID Number Tl!8000081205 <br /> 6.Tn`6' sgQ.,t +'Y'—' LEFN SYSTEMS INC <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name MAD039322250 <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. <br /> 8.Designated Faciliky Name and Site Address CLEAN HARBORS ENVIRONMENTAL SERVICES, I211 U.S.EPA ID Number <br /> 2247 S HIGHWAY 71 NE 69145 <br /> 308-235-4012 KIMBALL NED981723513 <br /> Facility's Phone: <br /> 9a. <br /> 9b,U.S.DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group{if aNo Type Quantity Wt.Nol. <br /> ny)) <br /> K 1. NA3082, HAZARDOUS WASTE LIQUID, DM P DOIDE 223 <br /> 0 N.0.S. , (LEAD), 911 PG III Z <br /> � DM P 223 <br /> 2 ( ORBENTSON CCONTAMINATED WITHEOI©)iiit: T" <br /> I Z= <br /> 3. <br /> 4. <br /> 14.5pecial Handling Instructions and Additional Information TSD;KP 80097192 8015429 CSG: u <br /> 1)ERG#171• <br /> 24H EMERgNCY#800-468-1760-CH/SK/TFI-Contract retained by generator confers a enly authori y <br /> on initial transporter to adti gr icubstitutea additional transporters on nenpra 0 - 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 labeled,'placarded,and are in all respects in proper condition for transport according to applicable intemafienal and national govemmental 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 EPAAcknowledgment of Consent, <br /> I certify that the waste minimization statement idenU'fled in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)I true. <br /> offerors PrintedfTyped Name Signature Month Day Year <br /> to 1, # <br /> 116.International Shipments Import to U.S. <br /> r__ Shit ❑Export from SPort of entrylexi <br /> . t: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> DC 17 Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> t— ;0mripikier 1 PrintedlFyped Name gnature � _ y Month Day Year <br /> 1-31 Ill <br /> 2 Transporter 2 Prints Name gna urs Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> •'a <br /> Facility's Phone: <br /> W 1 Be.Signature of Alternate Facility(or Generator) z Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,Codes for hazardous waste treatment,disposal,and recycling systems) <br /> cr) 3. 4. <br /> p 1 2' I <br /> -ODC-0- 1 <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest excepwill in Item 18a <br /> PrintedlTyped Name f Signat Month Day Ye <br /> 51 <br /> EPA or 000-22(R f i��7)3Previous editiitiilsar� e�802�2 4�n�r:qir.NATED FACILI EPA's e-MANIFEST SYSTEM <br />