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SL SK SHIP# 220778634 1111111111111111111111111111111111111 0 0 5 6 2 4 1 8 3 S K S Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number �� 2.Pag 1 of 3 E_m_ rlpy Rg%V!?Phone 4.Manifest Tracking Number WASTE MANIFEST CLOQt3'?'' '{?9 1 �fbt 1!f 1005624183 SKS 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) RO Lab Rubber Co. Iri*. 5834 W Lynne Rd TRACY CA 95344-9109 Generator's Phone: 209-836-0965 �z 6.T o e U.S.EPA ID Number T@ V SYSTEMS, INC- 7. 7.Transporter 2 Company Name U.S. PHumber 8.Designated Facility Name and Site Address SAFETY-KLE N SYSTEMS, INC_ U.S.E AIDNumber 6000 86TH STREET SACRAMENTO CA 95828 916--386-4913 _rt.)(,�6 ,I- (.:-J, Facility's Phone: 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes 1. NON'--RCRA HAZARDOUS WASTE, LIQUID t;M 134 o (AQUEOUS FARTS MASHER SOLUTION) t z 2. W 3. 4. 14.Special Handling Instructions and Additional Information TSD: SCA 719795'22 R015429 /201649 C31.; 4, �# 2 24 HR EMERGENCY 800-468--1760(SAFETY-KLEEN) D �`� -7�2 I- RUTH AS "AGENT-FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY 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 labeled/placarded,and are in all respects in proper condition for transport according to applicable in ational 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 EPAAcknowledgme of Consent. I certify th t ty waste minimization s4prent identified in 40 CFR 262.27(a)(if I am a large quantity generator r(b)(if I am a V all qu ti ' ne tor)is true. Generator's/ , r s Printed/Tyyw- Nam Signat Month Day Year l Icer`( ilC( J 16.Internaliontl Shipments Import to U.S. Export from U.S. Port of entry/exit: Z ❑ ❑ Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signatur Month Day Year 0- -vim �Lta ►..) � �� 12 121 116 QTransporter 2 Printe d NameSignature Month Day Ye 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number: 181b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLI 1 H141 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a It&) ed Nae .� i nature Month Day Year I EPA Form 8 00-2 ev.3-0Previous editions are obsolete. DESIG TED FACILITY T DESTINATION STATE(IF REQUIRI'D)