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9K SHIP# 223477573 III 111111111111 IN 11111111111111111111 0 0 6 1 9 3 9 2 9 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 ,C 2.Pa 1 of E e�cy jt Kns�ep 4.Manifest Trackin Number �1_ 0 ,L��l , �k 4� ._. ,to 00 6193929 SKS WASTE MANIFEST 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) '0 1._,.h Rubber G'va Inc. ?,E430 W Linne Rd Trac r '. CA 951304-9101 Generator's Phone: s. r�ttsp rtgr�cc r p>o neSYSTF.MS INC U.S.EPA ID Number TXR000081205 7.Transporter 2 Company Name U.S.EPA ID Number CI.._EAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 8.Designated Facility Name and Site Address CLEAN HARBORS GRASSY MOUNTAIN U.S.EPA ID Number 3 MILES EAST, 7 MILES NORTH KNOLLS EXIT 41, i;F r= 1--80 F!.Nt�t 1.5 !IT S4083435-884-9915 UT0991301748 Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1-NOIR RCRA HAZARDOUS WASTE SOLIDS, (SPIL- (1M 0 1,.- CLEANI.P NO FREE LIQUIDS `, qa RAGS/POLYPROPY!_FNE/DEBRIS OIL} z 2. L c7 3. 1 4. 14.Special Handling Instructions and Additional Information TSS BM 748133904219 RC 1.54429 CSG 4 HR EMERGENCY #1--800---468-1760 (SK ! TFI) i � L 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 classifield,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international 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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offeror's Printed/Typed Name Signature Month Day Year X 17 J 16.Internati nal Shi ment H ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Trans rt 1 Printed/Typed Name Signatur Month Day Year N TEUF uwr=t� h-c �'`- � Z 1 17 zQ Tran �ted[T Name Sign Month Day Year F-- o 18.Discrepancy 18a.Discrepancy Indication Space ❑ QuantityType yp Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: H 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U I Facility's Phone. w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) In 1. 2. 3. 4. 20.Designate Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manif st cept as noted in Item 18 Print a`e Sig atur Month Day Yeari , EPA Form 87Q0-2�(R v 05 Prev�ous editions are obsolete. D GNATED FACILIT TO DESTINATION STATE(IF REQUIRED)