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SSL SK SHIPS <br /> 00625590SKS <br /> Please print or type.(Form de ' red for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2650-0039 <br /> UNIFORM HmmoouS 1 Generator ID Number CAL000375509 z. 1 1.�4 17` 6 0063 5590 er <br /> SKS <br /> WASTE MANIFEST 1� <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> RD Lab Rubner Co. Inc. <br /> 8830 W Linne Rd <br /> TRACY CA 95304-9109 <br /> Generators Phone: 209-836-0%5 <br /> U.S.EPA ID Number T X 8000081205 <br /> 6'9Wff4-'WMff8SYSTEM€S INC <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS ENV I RONM4ENTAL SERVICES, IN U.S.EPA ID Number <br /> 2247 S HIGHWAY 71 NE 6'9145 NED981723513 <br /> KIMBALL + <br /> 308-235-4012 <br /> Facilites Phone: <br /> 98 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 W11Vol. <br /> a X '-NA3082, HAZARDOUS WASTE LIQUID, DM P D008 23 <br /> o N,O.S. , (LEAD), 91 PG III 3 1200 <br /> Z 2. <br /> LU <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Information TSD:KP 75766943 R015429 n CSG <br /> 24EHR EMOMENCY *1-800-468-1760 (SK / TI=I) b`'c 0-2-q <br /> AUTH AS :r " <br /> BY GEN TO RETAIN LIr-FNSpn SUB CARRIERS AS NEm R <br /> 15. GENERATOR'SfOrFEROR'S CER7MATION: 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 labeledlplacarded,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 terns or the al lched EPAAcknowiedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 282.27(a)(g I am a large quantity generator)or(b)(if i am a small quantity generator)is true. <br /> GeneratorslOfferors Printedlryped Name Signature YT <br /> ORI IT <br /> 16NRkUlfbonal Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of enbylexit: <br /> M Transporter signalure(for exports only): Date leaving U.S.: <br /> W 17.Transporter AduwwledgFnentof Receipt of Materials <br /> Transporter 1 Printedflyped Name Signature Monti <br /> Day Year <br /> o '99 (O <br /> C) <br /> QTransporter 2 PrintedtTyped Name Signatu Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> j U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> J_ <br /> U <br /> V LL Facilitys Phone: <br /> Month Day Year <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> • Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 20.Designated Facility Owner or pemtor.Certification or receiplpf hazardous materials covered by the manifest except as noted in ltem 18a <br /> PrintedlTyped Name Signature M Day Y <br /> f <br /> l <br /> EPA Form 8700-22(Rev.3-051) PFevious editions dre obsolete. NA FACILI TO ESTINATI )N STAT (IF REQUIRED) <br /> 1)7273245/40810194 <br />