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0053 2 9 4 7 7 SKS Please print or type.(Form designed for use on elite(12-pitch)typewriter.) / Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator!➢Number _ 2,PagQ 1 of 3�Em� pcy Respse Phge 4 4.Manifest Tracking Number ALI _:_t = WASTE MANIFEST 005329477 SKS S.Gengratges Name and.Mailing Address Generators Site Address(if different than mailing address) R, Lab Rubber -o Inc. 8830 W Linne Rd TRACY _ CA 95304-9109 Generators Phone: 6.Ttar�spalier a.Corppp y Nage -YST , � U.S,EPA ID Number T X RO@008,205 7.Transporter 2 Company Name U.S.EPA€D Number B,Designaled Facility Name and Site Address CLEAN HARBORS PUTTIDN'WI LLOWq LLF- U.S.EPA ID Number 2500 LOKLRN ROAD _ B�ITTOrt�#Wit_LOW q OSS 9?206 CPD980675 76 X61-76�-6L Facil'fi/s Phone: ga 91 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 W1.N01. 1. NON RCRA HA7ARDOU.S WASTE SOLIDS, (SPIE /�f�f]� ",,'• _ �-_:'' — o L CLEANUP NO FIEF LIQUIDS (L` RAS; /:PGLYPROPYLENE/DEBRIS OIL) z 2. 3. 4. 14.Special Handling;f adAdditional Information TSD.BL AL 801.54:9 CSG -7(2) ; s 4 HR EMERSENt:. C-800-46-8-17150 (SK / T FI) "VLjTH AS "119E .—F' AV SF{�.! TO RETAIN LIuEI�SEI] SLIP CARRIERS i�5 NECECei�RY 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 labeiedlpiacamed,and are m all respects in proper condition for transport according 10 applicable intematonai 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 AcknoVedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 282.27(a){If I am a large quantity generat r(b)(if I am a small quantity generator)is true. e torsls PrintedlTyped Name Si atuY Mpn_th ay 1(ea � ntemational Shipments /y� [_{� cla_l, fJ ❑Import to U.S. ❑Export from U.S. Port f entrylext: Transporter signature(for exports only): caving U.S.: w17,TransporterAcknowledgment of Receipt of Materials EE Trans 1 PrintedfTyp Name Signature M th �� Year o � f/ a Z Transporter Print !Typed Name Signature 4onth Day Year a t- 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 U ra Facility's Phone: ILLI 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19,Hazardous este Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. 20.Designated Facility er Operator:Certification of receipt azardous materials covered by the manifest except as noted in Item 18a PrfnledlTypedName �• Signature � Month Da EPA Farm7e -9�:�+ ,seditious obsolete. DESIGNATED FACII_ITYTO DESTINATION STATE(IF REQUIRED) .__ , .;