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SSL sly SHIP# 221731518 111111111111111111111111111111111111111 <br /> 0 0 5 7 & 9 0 5 4 S 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 CAL0003755092.Pal 1 of iLmgftywe rsePJaI&O 4.Manifest Tracking Number <br /> WASTE MANIFEST 11 005789054 SKS <br /> 5. enerator's Name and Mailing Ad cess Generator's Site Address(if different than mailing address) <br /> O Lab Rubber 6o. Inc. <br /> 8830 W Linne Rd <br /> TRACY CA 95304-9109 <br /> Generators Phone: 209-836-0965 <br /> I ftVjftfVR&eSYSTEMS, INC. U.S.EPA ID Number TXROOOOS120S <br /> 7,Transporter 2 Company Name U.S. P ID Number <br /> Cja <br /> 8-Designated Facility Name and Site Address SAFE TY-KLE ST IIS 4NC. U.S.EPA ID Number <br /> 6000 BOTH STREET <br /> SACRAMENTO CA 95$2$ <br /> 916-386--4913 CA0000084517 <br /> Facilitys Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,0 Number, 16.Containers 11,Tota! 12,Unit <br /> HM and Packing Group(if anyj} 13.Waste Codes <br /> No, Type Quantity Wt.NDI. <br /> 1HAZAK5OUS WASTE, LI _9F 134 <br /> o (AQUEOUS PARTS WASHER SOLUTION) <br /> l Dolil 2D <br /> z 2. <br /> ua <br /> 4. <br /> 14.Special Handling Instructions and Additional Information f ( �/,R015429 20 171 T_ff�"4 <br /> �7 1 <br /> 24 HR EMERGENCY # 800-4,5£3-1760(SAFETY-KLE `� Ub ( 1 S/ <br /> RUTH AS "AGENT-FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <br /> 15. GEN ERATOR'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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemational and 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 csrify that the waste minimization statement identified in 40 CFR 262.27(a){H I am a large quantity,generator)or(b)(if I am a small quantity generator}is true. <br /> Generators/Offerors PrintedlTyped Name Signatu Month Daay{ Year <br /> J 5 Intematlonal Shipments ` <br /> ❑Import to U.3 ❑Export from U.S. Port of entrylexlt: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LU 17.Transporter Acknowledgment of Receipt of Materials <br /> jj Transporter 1 PrintedlTyped Name <br /> O ; Signature Month Day Year <br /> CL <br /> y <br /> QTranspo 2 Pnnte y e Signature Month Day Year <br /> i <br /> 16.Discrepancy l <br /> 1Be.Discrepancy Indication Space El <br /> Quantity ❑Type ❑Residue ❑Portia!Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 486.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> F18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1 H141 2, 3. 4. <br /> 20.Designated Facility Owner or Operator:Certiftcagon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pir lfy d Name Mon Da Year <br /> Previous editions are obs DESIGN FACILIT�TODiZION STATE (1F REQUIRED) <br /> r <br />