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SSL SK SHIP# 226367400 II I II I II I IIID III�I�I IIS II II'I I I II III <br /> 0 0 6 3 9 1 4 6 8 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 1,Generator ID Number CAL000375509 2.Pagel of 3.Emew�b Respop,e Pf o 4.Manifest Trackiber SKS WASTE MANIFEST lI tt33 �t00 �FbtS 1( 0 SKS <br /> 5 Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> RQ Lab Rubber Co. Inc. <br /> 8830 W Linne Rd <br /> TRACY CA 95304-9109 <br /> Generator's Phone: 209-836-0965 <br /> 6.TriIgpwiG fJ,2pp�y iJ,na�g SYSTEMS INC U.S.EPA ID Number <br /> lHiltt �t 1 ( tr ttN TXR@00081205 <br /> 7.Transporter 2 CompaName U.S EPA ID Number <br /> CLEAN HA4BORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEANHARBORS OF BUTTONW I LLOW U.S.EPA ID Number <br /> 2500 LOKERN ROAD <br /> BUTTONWTLLQW , CA 931:06 <br /> 661-762-6200 CAD980675276 <br /> Facility's Phone: <br /> 9a 91b.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)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1. NON RCRA HAZARDOUS WASTE SOLIDS (SPIL DM P 352 - <br /> 0 L CLEANUP NO FREE LIQUIDS ZOL <br /> a RAGS/POLYPROPYLENEtDEBRIS OIL) <br /> LU <br /> W <br /> z 2. <br /> w <br /> 0 <br /> 3. <br /> a <br /> 14.Special Handling Instructions and Additional Information TSD:BL 77607476 8015429 <br /> 6 <br /> 24H EMERGENCY#800-468-1760—CHISK/TFI—Contract retained by generator confers a ar-tthi y <br /> on initial transporter to add or substitute additional. transporters on qenera .or' s behalf. <br /> 15. GENERATOR'S/OFFEROR'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 /> 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 Sign ture Month Day Year <br /> J 16.Internation5hipments <br /> z 1:1Import to U.S. ❑Export from U.S. UPort of entry/exit: — <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> OTransporter 1 Printed Typed Name � G 'vt Signature Month Da Year <br /> a- <br /> 0 <br /> S i 1�1 c�j l i <br /> rn <br /> Q Transporter 2 PrintedlTyped �� Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quantity El Type ❑Residue ❑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 /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> H <br /> a <br /> z <br /> N19.HazardoA Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <br /> w <br /> p 1 2. 3. 4. <br /> 20 Designated Facility 0 r Operator:Certification of receipt of zardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name Signature G �� �nt <br /> EPA 7`i i° � 2IJ%P /v4g editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />