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SV FSHATPO 223004716 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) form Approved.OMB No,2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2- z 1 of 3.Erne ncy Res onse Phone I".Manifest Tracking Number KS WASTE MANIFEST OAL060375509 1- _4 -1760 65 S 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) RO Lab Rubber Co, Inc. 8830 W Lame Rd TRACY CA 95,304-910995,304-9109 Generator's Phone: i�Qt9`1Lr � Ib`` U.S.EPA ID Number 6.Trans ort 1 Com ny Name �)(RBf� I SAFeETYwK�I"EN SYSTEMS IN 7.Transporter 2 Company Name U.S.EPA ID Number GLEAN .HARBORS ENVIR[NWENTA1. SVC INC. �Dt�:393��50 8.Designated Facility Name and Site AddressU.S.EPA ID Number CLEAN HARBORS �iRR,�aSY MOUNTAIN a 3 MILES FAST, 7 MILES N RTH KNOLLS EXIT 41, OFF 1-80 KNfl115 , UT 84@83435•-884--891 UTD9913017 48 Facility's Phone: ga. 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 any)) No. Type Quantity M.Nol. 0 1.W)N RCRA HAZARDOUS WASTE SOLIDS, (SPIL DM F 352 F L CLEANUP NO FREE L.I CKJ I BS RAGS/PID .YI ROPYLU:.NEIDEBRIS CHILI Z 2. W t7 3. 4. 14.Special Handling Instructions and Additional Information -SSD It GM 74346629 R015429 2'4 HR EMERGENCY #1-8010-468-1760 (SK f TFT)qEV ATTACHMENT 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 Gassified,pac ged, 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 t am a large quantity generator)or(b)(if I am a small quantity generator)is true. , Generator'sl0fferoes PrintedlTyped Name Signature Month Day Year J 16:International Shipments 11L- ❑Import to U.S. ❑Export irom U.S. Port of entrylexit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printedlryped Name Signature ^ Month Dayrr Year W L t t r tk I Lill. Signature Month Day Year z sporier 2 Prin Name . -77 F r 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: , 18b.Alternate Fadlity(or Generator) U.S.EPA ID Number J_ facility's Phone: Month Day Year W 78e.Signature of Altemate Facility(or Generator) E z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) W t 2 13. 4. Q 20,Designated Facili Owner or 0 erator:Certification of receipt of hazardous materials covered by the manifest except a noted in I 18 ; 1t Y Signature Sig f Printedfryp Na EPA Form 8700 2(Re(Rev.3-U!5) Previous editions are obslete. t DESIGNATED FACkLITY'111S COrY 11727324V407897%.