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�3S. SK .SHIP# 223958865 Y ► 111 1 � �I������E��li�������1��������1 f����l� <br /> 0062 a 6 4 2 0 S K 8 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Folin Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1 Generator ID Number CAL02 P 1 of E 101cy ns Pg 4.Manifest Tracking Number <br /> - <br /> WASTE MANIFEST 0 0 6 2 8 6 4SKS <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> RO Lab Rubber Co. IT1c. <br /> £t83 WL i.rr�t R <br /> TRACY CA 55:304--9109 <br /> Generators Phone: <br /> 6.Iraa�ppde[ Ccyppa SYSTEMS <br /> INC U.S.EPA ID Number <br /> T X ROOOOS 1 205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> C#_EAikl HARBORS ENVIRONMENTAL SVC INC, MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS ENVIRONMENTAL. SERVICES, IN U.S.EPA ID Number <br /> P-247 S HIGHWAY 71 <br /> KIMBALL , NF 69145 <br /> 308-235-4012 111"3.9817':?.5'j1 <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type 4uantiry Wt./Vol. 13.Waste Codes <br /> X 1-NA3082 HA7.ARDOUS WASTEE_IQUID, DM u P I312106 823 <br /> 00 N.O.S, , (LEAD), S, Pis III � L©� <br /> i 2. <br /> W <br /> C7 <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additonal Information TSD*.KP 7551331 78 R015429 C60. <br /> 1)ERG##1:7t• �j � <br /> 24 FIR EMOGEN Y #1-8100-468-1760 (SK / TF I) _ �� ✓ r� <br /> RUTH AS "AGENT <br /> BY GEN TO RETAIN LICENSED SUB CARRIERS AS NEC -SSAf�Y <br /> 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 classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper oondilion for transport according to applicable international 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 certify that the waste minimization statement idenfified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's10 erors Printed/Typed Name Signature Morntrh Day Year <br /> • 111 1511 <br /> J 16.Internal Shipm nts <br /> Z ❑Import to U.S. El Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Fe Transpo r 1 rinte IT ed Name Signature Month Day Year <br /> 0 r � <br /> a <br /> a pedNaCme Signature Month Day Year <br /> 1./(.. <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantityyp j El❑T e Residue Partial Re ectlon Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> LL. Facility's Phone: <br /> w 18c.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 /> 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of Wzardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name SignatureMir 1, k) _I nth D Ivitillryl <br /> JZ <br /> Ilk <br /> EPA F rm_$7Q-2 (R v. -0 Previous edl ions are obsol te. DESIGNATED FACILITYTO DESTINATION STATE(IF REQUIRED) <br /> f)7 c 4 /�t1181 194 <br />