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SSL SK SHIP# 225847277 <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 1 2.Page 1 of 3. mer Res e P 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000375509 1 gAul-i"o 011856240 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if dderent 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.Trans orter 1 Com any Name U.S.EPA ID Number <br /> SnFETY (LEEN SYSTEMS INC TXR000081205 <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 CLEANHARBORS OF BUTTONWILLOW U.S.EPA ID Number <br /> 2500 LOKERN ROAD <br /> BUTTONWILLOW , CA 93206 <br /> 661-762-6200 CAD980675276 <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 Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> 1. NON RCRA HAZARDOUS WASTE SOLIDS, (SPIL S DM J P 352 <br /> o L CLEANUP NO FREE LIQUIDS <br /> qa RAGS/POLYPROPYLENE/DEBRIS OIL) <br /> z 2. <br /> LU <br /> CD <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:BL 77065243 R015429 CSG; <br /> 24 HR EMERGENCY #1-800-468-1760 (CH ! SK / TFI) 4Z;t 7 <br /> AUTH AS "AGENT-FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described abov�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 intemational and national Bove ntal 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 /> 1 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 i generator)is true. <br /> Generator's/Offerord/Typed Name igna re Month Day ear <br /> D <br /> -J 16.Intemational ipments <br /> H ❑Import to U.S. ❑Export from U.S. Port of /exit: <br /> Z Transporter signature for exports only): Date le in U.S.: <br /> LU <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> 11-- Transporter Printed/Typed Name Signature Month Day Year <br /> Ix <br /> Z T 2 Printed/Typed Name Sign l Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity El Type El Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> LL Facility's Phone: <br /> Lo 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 2. 4. <br /> r <br /> 144 10 <br /> 126.Designated Facilityer Operator:Certification of receipt of tArqous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name j Signature Month a Y <br /> EP1 F�jnz@7 J2 (nR�431�&PPrgvi�ouus editio re obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />