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SK SH I P11 2230047 <br /> Please pont 'type.(Form designed for use on elite(12-pitch)iypewritair. <br /> Y.. Form Approved.OMB No.205040 <br /> UNIFORM NAZARDOuS 1.Generator ID Number 2.Pae 1 of 3.Ern�e�r e`_ncy ResManliest Tracking Number <br /> WASTE MANIFEST CIS.M3755 1—t{ipfd^4 1�5-1760 <br /> K <br /> 5,Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> RO Lab Rubber Co. Inc. <br /> 8834! W Linne Rd <br /> TRACY CA 95384-9189 <br /> Generatars Phone: 209-83£0~0965 r <br /> 6.Trans rler t C m a Name U.S.EPA ID Number <br /> S1�EW FI N SYSTEMIS ING TXROSMI285 <br /> 7.Transporter 2 Company Name U.S.EPA 1D Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD439322258 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS-ENV-I RUNWWAL SERVICES, IN U.S.EPA ID Number <br /> 2247 S HIER Y 71 <br /> KIMBALL , NE 69145 <br /> 388-235-4812 :NED98.1723513 <br /> Facli s Phons: <br /> ge 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 14.Containers 11.Total 12.Unit 13 waste Codes <br /> HM and Packing Group(if any)) No. Type Ouentiry w1Nol. <br /> oc X t'NA30821 HAZARDOUS ATE LIQUID, DM P D806 e23 <br /> Na Oa Sa, (LEAD), 9, PS III �J 4 <br /> z 2. <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information TSD I KP 74345629 R015429 CS6 3 <br /> 1)ERG11171 <br /> 24:SIR EMERGENCY 111.900-468-1760 (SK / TFI) # <br /> 15.1 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby deciare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,amd are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and t 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 certify that the waste minimization statement identified in 40 CFR 262.27(a)(I I am a large quantity generator)or(b)(if I am a small quantity generator)is hue. 1 <br /> GeneratoesfOReroes Prirdedffyped Name Signature Month Day Year <br /> V �7 <br /> - 16:lw1ematR7WSh7Pman1s <br /> f- ❑Import to U.S. ❑Export from U.S. ` Pori of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> 17.TransporterAcknowtedgmaril of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature /� Month Dray Year <br /> U G 7 <br /> Ed III <br /> p2 Pr <br /> Name re Month Day Year. <br /> 1pt:fEil 7-11 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fufi Rejertinn <br /> Manifest Reference Number. <br /> 18b.Alternate Fad y(or Generator) U.S.EPA ID Number <br /> V <br /> LLC Fecitity's Phone: <br /> W 1 Bc.Signature of ABemate Facility(or Generator) Month Day Year <br /> 4 <br /> Z <br /> 19.Hazardous waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2,.Z 3. 4. <br /> IC) <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18A <br /> Printer fyped NameSignature Month Day tYear <br /> I0 !q <br /> EPA Form 8700.22(Rev.3-05) Prevrous editions are obsolete. DESI ATED FACILITY TO GE TOR STATE(IF REQUIRED) <br /> 86 <br /> 117273245/418154 <br />