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SSL SK SHIP# 224256280 Ill 11111111111111111111111111111111111 <br /> 0 0 6 5 3 0 0 7 8 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 2.Pae 1 of 3.Emer ency Response Phone 4.Manifes'6530078 <br /> Tracking Number <br /> WASTE MANIFEST CAL000375509 � 1-8�Ow468-1760 0 6 5 3 0 0 7 8 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> RO Lab Rubber Co. Inc. <br /> 8830 W Linne Rd <br /> TRACY CA 95304-9109 <br /> Generator's Phone: 209-836--0965 <br /> 6.Trans orter 1 Com an Name U.S.EPA ID Number s,}c <br /> SAFETY-K�E7EN SYSTEMS INC TXR00008120S <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> UbD <br /> 8.Designated Facility Name and Site Address SAFETY--KLEEN SYSTEMS, INC. U.S.EPA ID Number <br /> 6000 88TH STREET <br /> SACRAMENTO F GA 9SB28 <br /> Facility's Phone: 916-386-4913 CA{)00008451 <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> '-NON--RCRA HAZARDOUS WASTE, LIQUID G 134 <br /> o (AQUEOUS FARTS WASHER SOLUTION) ` tiM 20 <br /> z 2. <br /> w <br /> C9 <br /> t <br /> 3. <br /> p <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:SCA 7562?275 801542920182 CSSG:24 <br /> 24 HR EMERGENCY # 800-468-1760(SAFETY-KLEEN) 1 ) U( "u,0i "(S--C1 <br /> AUTH AS "AGENT—FOR" LICENSED <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 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 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. <br /> Generator's Offeror's Printed/Typed Nam Signature Month Day Year <br /> xx 161 10911F <br /> J 16.International Shipments' <br /> Z 1:1 Import to U.S. ❑Export from U. . Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedlTyped Name Signature Month Day Year <br /> Q Trans o 2 Printed;yped Name Signature Month Day Year <br /> f 1 le <br /> "O' <br /> Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> H 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> IL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU G 1 <br /> H141 2. 3. 4. <br /> nated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> I:Prt:ed/Xam���-' � lure Month �D3y Year <br /> Ig lj ^ <br /> EPA Form 8700-2ev.3-05) Previous editions are obsolete. ESIG A ED FACILITY TO DESTMATION STATE(IF REQUIRED) <br /> 1)14941/ 6023 <br />