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SSL SK SHIP# 226367406 II I II I II I VIII VIII II III II ILII I I I)III QA 63914695 KS Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.P e f 3. me Re e P 4.Manifest Tracking Number WASTE MANIFEST CAL000375509 - - E -�%0 1006391469 SKS 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) RO Lab Rubber Co. Inc. 8830 W Linne Rd TRACY CA 95304-9109 Generators Phone: 209-836-0965 6.7rWE�YComp U99 SYSTEMS INC U.S.EPA ID Number TXR000081205 7,Transporter 2 CompanyNameU.S.EPA ID Number CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD0393222250 8.Designated Facility Name and Site Address CLEAN HARBORS ENVIRONMENTAL SERVICES, IN U.S.EPA ID Number 2247 S HIGHWAY 71 KIMBALL , NE 69145 NED981723513 308-235-4012 Facility's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes X 1_ NA3082, HAZARDOUS WASTE LIQUID, �? DM �� P DOO 223 of N.O.S. , (LEAD), 99 PG I11 z 2. LU t9 3. 4. 14.Special Handling Instructions and Additional Information TSD:KP 77607476 R015429 !� CSG: 1)ERG#171• � 24H EMERGENCY#800-468-1760-CHIS/TFI-Contract retained by generator confe2Wrency authori y on initial transporter to add or substitute 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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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 a small quantity generator)is true. Generator's/Offerors Printed/Typed Name Sign ture Month Day Year 10 —J 16.International Shipments z ❑Import to U.S. ❑Export from U.S. P of entry/exit: Transporter signature(for exports only): D e leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials U �2 Transporter 1 Printedrryped Name Signature Month Day Year a- r7 eAl ZZ Transporter 2 Printed(fype a Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 181b.Alternate Facility(or Generator) U.S.EPA ID Number J U V Facility's Phone: C3 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) p 1 2. 3. 4. ) I I I20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pdnted/Typed NameMonth Day Ye - 9� 0 ,— ce*n. P�L', 1) 'L� I /D K I) X] EPI}rZQO��22(R�4�0�)iP�eiv' 4 editions are ob lete. D IGNATED AGILITY TO DESTINATION STATE(IF REQUIRED)