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;i SK S'riIry# 220866411 <br /> 005728929 + KS <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.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAI-000375509 1-800-468-1760 005728929 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> RO Lab Rubber Cc. Inc. <br /> 8830 W Linne Rd <br /> TRACY CA 95304-910 ' <br /> Generator's Phone: 209-836--0965 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY-KLEEN SYSTEMS, INC. TXR000081 <br /> 7.Transporter 2 Company NameU. ID Number <br /> L]Lo , 3� <br /> 8.Designated Facility Name and Site Mdress U.S.EPA ID Number <br /> CLEAN HARBORS BUTTONWILt_OW, LI-C <br /> 2500 LOKERN ROAD. <br /> Facility's Phone: <br /> F?I1TTI]NW I LLOW , CR 93206E,61-762-F2 00 CPD98@67927F, <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Cods <br /> HM and Packing Group(if any)) No. Type Quantity Wt./Vol. <br /> 1. NON RCRA HAZARDOUS 13ASTE SOLIDS, (SPIL P 352 <br /> L CLEANUP NO FREE LQUIDS <br /> RAGS/POI._YPROPYL_ENE/DEBRIS OIL) <br /> Z z. <br /> W <br /> C7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> `-.:aD:Ht.. 7c.2 070667 R01-5-; <br /> E4 HR EMERGENCY #1-810--4.68-1760 (SK / TFI) <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are ply 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 international.alld 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 Acknowled a onsent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity gener for or(b)(if I am Ornall quantity upwai r i rue. <br /> Generators/Offerors Printed/Typed N Signa Month Da\ Year <br /> [ ►%� `1 <br /> J r7international Shipments <br /> Z 1:1 Import to U.S. ElExportfrom U.S. Port of entry/exi <br /> Transporter signature(for exports only): Date leaving U. <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedrryped Name Signature Month Day Year <br /> N <br /> ZZ Trans er 2 Printed/Typed Name natur Month Day Year <br /> H <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 /> J <br /> U <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19.Hazardou aste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. / 2. 3. 4. <br /> 20.Designated Facility Aerator:Certification of receipt of haz <br /> #fdous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature a Ygai <br /> EPA Form 8700-22( ev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> _ .`4078979f� <br />