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SSL 2i q 7z�� Illlllflllllllfl �II�IfIIiflfllllifll <br /> Please rotor � 0 0 5 4 4 1 2 3 S K s <br /> p type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No,2950-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator IDNumber CA[OG037��©� 2.Pagel of 31Err �epcyfj se�h 4.Manifest TrackINumber (� <br /> WASTE MANIFEST i Q 05445123 SKS <br /> S.Generators Name and Mailing Address Generators Site Address(if different Than mailing address) <br /> RD Lab Rubber Co. Inc. <br /> 8830 W Linne Rd <br /> TRACY CA ?S304-?10? <br /> Generators 209-836-096S <br /> 6'�a �°Rfn SYSTEMS, INC. U.S.EPA ID Number TXRO00081 <br /> 7.Transponer2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Sb Address SAFETY—KLEEN SYSTEMS, INC. U.S.EPA ID Number <br /> 6000 88TH STREET <br /> SACRAMENTO CA 95828 <br /> 916--386-4913 CA000oos41 <br /> Fadliys Phone: <br /> ga. 91b.U.S.OOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unh 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtNoI. <br /> 1 NDN—RCRA HAZARDOUS WASTE, LIQUID DM ZO G 134 <br /> o (AQUEOUS PARTS WASHER SOLUTION) <br /> z z <br /> LU <br /> M <br /> 4. <br /> 14.Special Handling Instructions and Additional Inhumation TSD:SEA 70405974 8015429 201625 Csc�:774 <br /> 24 HR EMERGENCY # 800-468-1760(SAFETY-KLELN) / - <br /> RUTH AS "AGENT-FOR" BY GEM TO RETAIN LICENSED $UP CARRTERS AS NECESSARY <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 labeledlplacarded,and are in all respects in proper condition for trensport according to applicable intemationaland 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(d€am a large quantity generator)or(b)('ri I am a small quantity generator)is We. <br /> Generetoes101feroes Pr ntedrryped Name SignatureMonth Day Year n 144,e <br /> _ <br /> 16.International Shipments <br /> H ❑Import to U.S. ❑Export from U.S. Port of entryJe.it: <br /> = Transporter signature(for exports only): Data leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Translp5w4 Printedfryped Name S' Month Day Year <br /> aJMV-W 1 -716 11/0 <br /> Q <br /> Transporter 2 PrinledlTyped Name Sig aW Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Fad lily(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> W 18c.Signature ofAhemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. H141 2. 3. 4. <br /> 20.Designated Facility Owner .perator.Certification of receipt of hazardous materials covered by except as noted in Item 18a <br /> Primed/typed Name { SignatureDay_ Y r <br /> EPAFpjf3700-y1(ft3�P Previous editions are obsolete. DESI ED FACILITY TO DESTINATION STATE(lF REQUIRED) <br /> 11 1981 - d <br />