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o z 3 ZzIIN IIiININ� lllullll <br /> SSL Si: SHIN# wG4@B:�iC4 &, 72 <br /> 0 0 6 4 6 2 0 4 0 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 CAL-000375509 <br /> 2.Pag 1 of 3.ErAe�gcy RggQpns�phQn 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 #itjf 4F�t3 1 jt r 006462B40 SKS <br /> 5,Generators Name and Mailing Address Generator's Site Address(it different than mailing address) <br /> RO Lab Rubber Co. Inc. <br /> 8830 W Linne Rd <br /> TRACY CA 95304-9109 <br /> Generators Phone 209-836-0965 <br /> 6.INp YC�m�meSYSTEMS INC U.S.EPA ID Number XR0000812�'S <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 GRASSY MOUNTAIN U.S.EPA ID Number <br /> 3 MILES EAST, 7 MILES NORTH KNOLLS EXIT 417 OFF I--80 <br /> KNOLLS , UT $4Q183 <br /> 435-884-8915 UTD991.30i748 <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 /> HM and Padang Group(if any)) No. Type Quantity W1./V(1. 13.Waste Codes <br /> '-NON RCRA HAZARDOUS WASTE SOLIDS, (SPIL DM 3�� P 3520 L CLEANUP NO FREIE LIQUIDS } <br /> RAGS/POLYPROPYLENE/DEBRIS OIL) 1 <br /> Z 2. <br /> LLI <br /> C7 <br /> 3. <br /> 4. <br /> 14.Spectal Handling Instructions and Additional Information TSD•GM 7510 5119 8015429 CSG: <br /> 24 HR EMERGENCY #1--800--468--1750 (CH / SK / TFI) k a1�SEE AT�iZHMENT � <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 labeied/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 certrfy that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(i s I quanfiUenerator)is inia. <br /> Generators/Offerors PbnledlTyped Name Sig re Iffi Month Day Year <br /> p2 <br /> N <br /> ri 16.Intemationa Shipments <br /> F ❑Import to U.S. El Export from U.S- Pciilkof en xit: <br /> K Transporter signature(for exports only): Date leaving U.S.: <br /> W17.Transporter Acknowledgment of Receipt of Matehais <br /> Transporter 1 Print Nie Signature Man�th Day Year <br /> O '�f•/ir■ i SJ! O is IV <br /> CL <br /> Z Transporter 2 PnnledfT a ame Signature Month Day Year <br /> F_ <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> LL Facility's Phone: <br /> IM <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazy us Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. hf� :­ <br /> 12. 3. 4. <br /> 20.D ignated Facility Owner qt Operator.Certification of receipt of hazardous materials covered by the manifest except as naiad i tem 18a <br /> Pante add Name Sign j 1 n <br /> ( [ <br /> EPA Form 8700 22(Rev.3 05} revious editions ad obsolete. SIGNATED A ILITY O DESTINATION STATE#REQUIR D) <br /> 1)7273242/40789796 <br />