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SK SHIP# 2220066401 <br /> (1 C15 - 2 B 9302 K S <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 Track Number <br /> WASTE MANIFEST <br /> AL001a37s5013 1 0 0 5 7 8 9 3 0 SKS <br /> 5.Generators Nameand Mailing Address Generators Site Address(if different than mailing address) <br /> RLI Lab Rubber Co. Inc. <br /> 11330 W L.inne Rd <br /> `RACY CA 95304-910'? <br /> Generarors Phone: 209-836'"0965 <br /> 6.Tra�rT Company Name �r U.S.EPA ID Number <br /> f•1 N SYSTEMS,EMS, I NC. <br /> 7.Transporter 2 Company Name !, +�r C� U.S.EPA ID Number,J3 2c D <br /> -39 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SARA JOSE 1 U.S.EPA IID�N`/umber <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> 406-441-0962CAD059494310 <br /> Facility's Phone; <br /> ga gh.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Tmai 12.Unit ' <br /> HM and Packing Group(if any)) No, Type Quantity Wt.Nol. 13.Waste Codes <br /> X3082, HAZARDOUS WASTE LIQUID, P D006 223 r <br /> N,Q,S., (LEAD), 9, P6 I I I <br /> W <br /> LU <br /> W <br /> � r <br /> 3. r <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> TSD:SJ 72070657 R015429 CSE:, <br /> I)ERG#171, <br /> 244 HR EMOGFNCY #1.-800-468-1760 (S14 / TFI) �d ✓TO <br /> 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, <br /> marked and labeletllplacarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations.If export shipment and I am the Primary <br /> Export ,I ceN the merits of this consignment conform to the terms of the attached EPA AcknoWedgment of Consent. <br /> I cerci t at waste imizahon s 'd in 40 CFR 262.27(a)(R I am a large quantity,generator)or(b)(4I am a small quantity generator)is true. <br /> Generators mrs Prin !Typed N s Signature Month Day Year <br /> A Ix LOCA- 2U-V(T- I I I In I 1(p <br /> � 1 .Internatio I S' <br /> 2 Export from U.S. Port of entrylexit <br /> Transporter signature(for exports onZ1.11S. <br /> Date leaving U.S.: <br /> W 17,Transporter Acknowledgment of Rerzi aterials <br /> Transporter 1 Printedrryped Name Signature Month Day Year <br /> 2w 1 ` 1 l <br /> Q Trans er 2 Printed(iyped Name n S Month Day Year <br /> 18.Discrepancy JV <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Pura Rejection ❑Full Refection <br /> Manifest Reference Number: <br /> 186.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> W Faciliitys Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> r <br /> 4 <br /> Z <br /> 19.Hazardous Waste a Management ethod Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 1 2, 3. 4. <br /> 20.Designated F Tliry Owner or Operator:Certification of of hazardous materials covered by the manifest except as ncled in Item 18a <br /> PrintedRyped Nae i Signatu Month Day Yea <br /> EPA Form 8700-22(Rev.3-05)Previous editions`Jar�erobs'o'I"IL. DESIGNATED F ILITY DESTINATION STATE(IF REQUIRED) <br /> 1)7273245/4081,1 <br />