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'•�I'. -�i�Z�#2Z "'i-.r��� (�II��I��III�III'��III�III�I�III���I� <br /> 0 0 6 3 2 5 5 8 9 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> .Generator ID Number 2.Pae 1 of E e cy R ns 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS C'AL 1(10111,'17cc.�0r.� '__ �� _49917r,6 <br /> WASTE MANIFEST ' 006325589 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 /> 3830 W Linne Rd <br /> TRACY CA 95304-9100, <br /> Generator's <br /> Phone: �2 09-836-0965 <br /> 6. C P.k_ �leSYSTEMc INC U.S.EPA ID Number TXRQt0010+ 1205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> F:`I_EAN HARBORS ENVIRONMENTAL SVC INC. MAD039322 50 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS GRASSY MOUNTAIN U.S.EPA ID Number <br /> 3 MILES EAST, 7 MILES NORTH KNOLLS EXT"r tr1, i:;�'c I-..60 <br /> KNOLLS , UT 84083 <br /> IJTD99130174 <br /> 435-884-8915 ? <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM <br /> and Packing Group(if any)) No. Type Quantity Wt.Nol.af <br /> ' NON RC=RA HAZARDOUS WASTE SOLIDS, (SFrIL "; ' P 35 <br /> O (_ CLEANUP NO FREE LIQUIDS ®a <br /> RAGS/POLYPROPYLENE/DEBRIS OIL) <br /> z 2. <br /> LU <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information T 3D:GM 75 766943 RO 154C 9 <br /> -14 HR EMERGENCY #1-800-468-1760 (SK / TFI) ho <br /> '�t_E PTT^rHMr-,N <br /> 15. GEN ERATOR'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 Name SignatureMonth Day Year <br /> )`��to T,,-&N7N I— ly LAJnkaJX-A* lot I cq I le <br /> J 16 International Shipments <br /> ❑Import to U.S. El Export from U. Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> W Transporter 1 PrintedlTyped Name Signature Month Day Year <br /> C <5TIe-NJC 16oc� I lff <br /> Q TransDQLLer 2 Printed/Typed Name / r Signature Month Day Year <br /> 18 Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity Type j 1 <br /> ❑ El ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> H 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> U <br /> Q Facility's Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. � � 2. 3. 4. <br /> 20.Desig ated Facility Owner erator:Certification of receipt of hazardous materials covered by the mani st a pt as tided in Item 18a <br /> Name Si atur 7Ton M <br /> Y <br /> \J <br /> ErA7,.trl 4Q- ?(R v 3�05�p�r v us editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 1 7, fes. L. 7. <br />