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sq 1SK SHIP# 223959934 II�I�I�II�IIIIII'��II�III��IIIII��II� 0 0 6 2 8 6 4 1 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 2 Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number �/�+ WASTE MANIFEST CAL000375509 Z -0 006286419 SKS 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) RO Lab Rubber Co. Inc. 8830 W Llnne Rd TF21?CY CA 95304-91',x,9 Generators Phone: 209--836-0965 6.Trans orter 1 Com an Name U.S.EPA ID Number �'Rl�ETY-KLFyEN SYSTEMS INC TX13000081205 7.Transporter 2 Company Name U.S.EPA ID Number CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD@393222501 8.Designated Facility Name and Site Address CLEAN HARBORS GRASSY MOUNTAIN U.S.EPA ID Number 3 MILES FAST, 7 MILES NORTH KNOLLS EXIT 41, OFF I-80 KNOLLS � 11T 84083435-884-8915 UTD991301748 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 I Wt.Nol. 13.Waste Codes '.NON RCRA HAZARDOUS WASTE SOLIDS, fSF'IL r)! © ;'" of L CLEANUP NO FREE LIQUIDS 5 RAGS/POLYPROPYLENE/DEBRIS OIL) Z 2. w C7 3. 4. 14.Special Handling Instructions and Additional Information TSD;GM 751 331 78 R015429 ;SG Q� :'4 HR EMERGENCY #1-800-468-1760 (SK / TFI) V t5,-;a5 :t=c ATTA( HMFNT 15. GENERATOR'S/OFFEROR'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 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. Generators/Offerors Printed/Typed Name Signature Month Day Year F 1 16.International Shipments ❑Export from U.S. Port of ent /exit: F- El Import to U.S. p ry z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 P'ntedfTped ame Signat Month Day Year a IS 1+ Z Tran rinriqgfryped Name Signature Month pay Year yZD H 41 17 V7 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity Type ❑ ❑ j ❑Full Rejection ❑T Residue Partial Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U IFacility'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) 0 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the ma es xcept as noted in Item 18a Pdpted"Name S net Jh D Yew EPA Form 8760-22 3-05 revious editions are obsolete. IG ATED FACILITY TO DESTINATION STATE (IF REQUIRED)