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SSL SR ; NIA# 221171141 �� i " <br /> Qp �= <br /> iarttt#Cppgo�ied,QMBNo -0039 <br /> R60 <br /> Please,print or type (Form designed far use on rllte(12-pitch)typewriter:).. 4,:Manrtgsi TraGNngNrtmtrer <br /> IFNIF iIVA HAZJIRDOUS. 1.Generator ID Number 2.Pag of 3 m R se <br /> C L0100375569 -� <br /> WASTE"NIFEST <br /> 5.Generator'sName and Mailing Address iweratoes Site Address(if different than mailing address) <br /> ,C] Lab.Rubber Co. Inc. <br /> 30 W Linne Rd CA 95304-9109 <br /> TRACY <br /> 4. Generators Phone: <br /> �o U.S.E.PA 1D number T X ROIBO$812135 <br /> 209-836-101965 <br /> SYSTEMS, INC. <br /> U.S.ERAID Number <br /> 7.Transported Company Name <br /> 8 vesignatedFacilityNameandSiteAddress RBOR ARAGONITE L.LC U.S.E:PAlDNumber <br /> 11600 NORTH APTUS ROAD LIT 84 29 <br /> ARAGONITE + UTD981552177 <br /> 435-884-81QIO <br /> Facility s Phone. : — <br /> 1.9b U S.DDT Description(including Proper Shipping Name;Hazard Gass,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a i 7d , Gdany}) No. Type <br /> Quantity <br /> Wt./Vol- <br /> HM kagroup( _ <br /> L 77 t itJ' RC1Nt4EN?fWLL.Y 'HAZARDOUS � CF 3��� P 141 <br /> ,v �ST ES SOLIDN Q.S., (CONTAINS <br /> 1TYL BENZYL PHTtiXATE), 9, PS I I I <br /> 5Y <br /> 3: <br /> 4_ <br /> 14:Speaal Handling Instructions and Additional Information 723911052 8015429 "+ <br /> ,.1)ER#1711 I) <br /> ��2C�ri tVC <br /> Y <br /> #1 <br /> --600 <br /> 1 <br /> . TF <br /> �t HR <br /> 7 ATTACF414ENT - <br /> A 5.''GEIEIZA7t2ft'SfOFFEROR'S CERSEFfCATE0H:1 hereby declare that the contents of this consignment are fully a accura y <br /> desert <br /> above by the proper shipping Warne,and are classified,packaged. <br /> mar1ced;and labeledlplacarded,and are in all respects in proper condition for transport eocording to appl icable in mationaian rational v.mmentai regulations:if export shipment and l am the Primary <br /> 6p.6rter,t certify that the contents of this consignment.eonfortn to the terms of tits attached EPAAckno vEedgm. t of Consen <br /> 1 cer*ffiat the waste minimization statement ideriffiied in 40 CFR 282.27[a)[if I em a targe quantity geiEirator) [b)[if I am smail qu tity,gene r]is true. Month pay Year <br /> eneratorsl rs PriMedlType <br /> d Name Signature <br /> 16.intematidna Shipments ❑Imp <br /> F., port U.S. ❑Export from U.S, ntryle't <br /> -K3wsporte.rSignature(for exports only). Date leaving U.S <br /> 17.Trans porter Acknowledgment of Receipt of Materials C Mo�gy Day Y r, <br /> T itsporterlPnrrtedlTypedName Signa <br /> a n c / r r V�J`U� Month Da!r Year <br /> er dTited/� pit/Name <br /> 18.Discrepancy <br /> 188.Discrepancy Indication SpaceQuantty TyQe` ❑Residue ❑Partil'Rejection ❑Full Rejection <br /> ❑ <br /> Manifest Reference Number. <br /> U.S.FPAtD Number <br /> 18b.Alternate Facility(or Generator) <br /> J <br /> U <br /> Facility's Phone: Month Day Year <br /> 18c.Signature of Alternate Facility(or Generitor)LU <br /> a <br /> z <br /> 19_HazardousWaste Report:Management Method Codes(i.e.,codes for hazardous waste treatment,disppsai;and recycling systems) <br /> 1 2 4 �"LU <br /> 3 t <br /> C: <br /> 20.Designated Facility owner or Operator.Certification of receipt of hazardous materials covered by the maiiifestexcepl as noted in Item 18a Adonth D'f ," Year <br /> PrintedrTyped Na e. S'gnature <br /> EPA F 700- 2 li v: -0l Previous ecltions are'obsolete. AE$IGNA E-ILtT.Y TO DESTINATION STAT1~(IF REQUIRE } <br /> 1)�T� M f 1 3 s23S <br />