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1581- SK SHIP# 224862558 (` r n p'6"'b 6 2 E 4 1 S K S <br /> type. Form designed for use on elite(12-pitch)typewriter.) V Y l.C.� Form Approved.OMB No.2050.0033 <br /> Please print or pe.( g P )N <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Pa 81 <br /> of 3.Emer 0 Res�wnse Phone 4.Man{fest7meki lumber <br /> WASTE MANIFEST CAL000375509 1-880-46fi-1760 0 0 6 4 b 2 er 41 SKS <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> RO Lab Rubber Co. Inc. <br /> 8830 W Linne Rd GA 95304-9109 <br /> TRACY <br /> Generators Phone, 2109-"836-0'965 U.S.EPA ID Number <br /> 6.Trane iter 1 Com n Name TX 8000081205 - <br /> SAF�ETY-KEN SYSTEMS INC <br /> 7.Transporter 2 Company Name - U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD$39322250 <br /> S.Designated Facility Name and Site Address CLEAN HARBORS ENVIRONMENTAL SERVICES, IN U.S.EPA ID Number <br /> 2247 S HIGHWAY 71 NE 69145 <br /> KIMBALL + NED981723513 <br /> 308-235-4012 <br /> Facility's Phone: <br /> 9b.U.S.DOTesc <br /> Dription(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9,. Quantity M.Nol. <br /> HM and Packing Group If any)) No. Type , <br /> at X 1NA3082, HAZARDOUS WASTE LIQUID, DM Q P D008 223 <br /> or N.O.S., (LEAD), 9, P6 III Z' !� <br /> z 2. <br /> W <br /> 4. <br /> 14.Special Handling Instructions and Addili net Information TSD.-KP 76105119 R015429 �7 CSG <br /> 1)ERG#171• l� <br /> 24 HR EMERGENCY #1-800-468-1760 (CH / SK / TFI) <br /> rr <br /> 15. GENERATOR'SfOFFEROR'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 kabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.9export shipment and I am the Primary <br /> Exporter,I certify,that the contents of this consignment oonfonn 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 U=II quantity qenerator is true. <br /> Geaerator'sl eroes Printed/Typed Name S n re M!36 1 ��r <br /> Vl G� fl� 1 g <br /> 16.International Shipments ❑Ex rtfrom U.S. Pon of a lex4: <br /> r ❑Import to U.S. Po <br /> Z Transporter signature(forexpons only): Date leaving U.S.: <br /> 09 17.Transporter Acknowledgment of Receipt of Materials <br /> W Merit Day Y <br /> � Tmnsporterl PnntedlTtped_Name Signature y b I� <br /> o SsTIITJI�PxI /`XJ lV <br /> M Day Year <br /> 2 <br /> Transporter Printe Name Signature <br /> (/O <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b-Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rai Facility's Phone: <br /> LOU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> 19.Hazardous Waste Report Management Method Codes(i.a,,codes for hazardous waste heatmenl,disposal,and recycling systems) <br /> ' n 1. 2. <br /> 3. 4. <br /> 20.Designated Facility Owner or Operator:Cerfification of receipt of hazardous materials covered by the manifest except ed in Item 18a <br /> PrintedRyped Name z Signatureii&. Montlt Day Year <br /> nLZ I- , <br /> EPA Form 8700-22(Rev-3-05L Previous editions are obsolete. DESIG ED FACILITYTO DEST ON STATE(IF REQUIRED) <br /> 1)7273245/4081194 <br />