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Sit-SK SHIP# ; <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Pae 1 of 3.Eme envy Res nse!E1 <br /> Manifest Tracking Number <br /> WASTE MANIFEST C`AL000375509 1- - 3 6 9 9 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if diRerent than mailing address) <br /> RO Lab Rubber Co. Inc. <br /> 8830 W L.i tine Rd <br /> TRACY CA 95304---9109 <br /> Generator's Phone: 209-836-10965 <br /> 6.Trans ortor 1 Com n Name <br /> N" <br /> SY--KLEyEN SYSTEMS INC U.S.EPA IDNumber <br /> 7'x R0O0081 n- 5 <br /> 7.Transporter 2 Company Name <br /> CLEAN HARBORS ENV I RENTAL SVC INC. U.S.EPA ID Number <br /> 039322250 <br /> s. 8.Designated Facility Name and Site Address CLFAN HARBORS GRASSY MOUNTA I N <br /> U.S.EPA ID Number <br /> a 3 MILES EAST, 7 MILES NORTH KNOLLS EXIT 41, OFF I-80 <br /> 435-884-'8915 KNOLLS , UT 84083 <br /> Facility's Phone: UTD91-91301748 <br /> k9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit <br /> No. Type Quantity Wt./Vol. <br /> 13.Waste Codes <br /> c <br /> 1.NON RCRA HAZARDOUS WASTE SDE-IIS, (SAIL DM F �_ <br /> L CLEAMJP NO FREE LIQUIDS <br /> RAGS/PO1,YPR(IPYLENE/DFBRTS OIL.) <br /> W <br /> Z 2. <br /> W <br /> C7 <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Information <br /> TSD.-GM R015429 CSG.- <br /> P4 <br /> SGac4 HR EMERGENCY #)--800--468-3 760 (SK 1 TF.I) <br /> - <br /> 15. GENERATOR'S10FFEROR'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 labelediplacarded,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 /> Generatoesl0lferoes PrintedlTyped Name Signature <br /> �j Month Day Year <br /> r-116.International Shipments -71 � <br /> EJ ❑tmport to U.S. Export from U.S. Port of entry/exit: <br /> Z Transporter signature(fir exports only): Date leaving U.S.: <br /> w17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedlTyped Name EVE Signature <br /> N <br /> Month Day Year/k .�', (J_? I �] <br /> Z <br /> Tran 2 PrinfedlTyped Name <br /> Q + ignature_ <br /> /� Month Day Yea <br /> C 1 Com/ `' ✓� n � ��ia' / <br /> 1$.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type EJ Residue <br /> ❑Partial Rejection El Full Rejection + <br /> 18b.Altemate Facifi Manifest Reference Number; <br /> ty(or Generator) <br /> -� U.S.EPA ID Number <br /> V <br /> Facility's Phone: <br /> uUu 18c.Signature ofAltemate Facility(or Generator} <br /> Z Month [Jay Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. <br /> 4. <br /> 2f}. gnated Facility tier or Operator. rt f catlan of receipt of hazardous materials covered by the manifest ecce t as noted i tem 1::�j <br /> Pdnte acne =ff <br /> Signature <br /> r � �? rl EPA Fo 00-22(Rev. 05� Previous editions are obsolete. ' <br /> 1)7273242/4 DESIGNATED FACILITY' CO Y <br />