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SIS SH I P# 232846W8 Please pnnt or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generelor ID Number �AL0�2�3817 2.Page]of 3.Eme{�pf Re�sgoQ$e PJ>op�� 4.klanifest Tracks Number WASTE MANIFEST 1 1 'Aitl—t}tsQ" ! 0077 - 8052 SKS 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) A & D Rubber Products Company, Inc. 1438 Bourbon St STOCKTON CA 95204-24134 Generators Phone: U9-941-0101a SYSTEMS INC U.S.EPA ID Number TX#t4 OSI M 7.Transporter 2 CompaName U.S.EPA ID Number CLEAN HAWBORS ENV SVC INC. MADS3932MID 8.Designated Facility Name and Site Address CLEAN HARBORS OF W I Ltd INGTON U.S.EPA ID Number 1737 EAST DENNI STREET R I LIri I NGTL#V * CA 90744 CAD044429835 310-535-9998 Facility's Phone- ga 9b_U.S.DOT Descripticn(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11 Tota= 12.Unit 13.Waste Codes HM and Packing Group(if any)) No Type Quantity WINol. NON RCRA HAZARDMJS WASTE LIQUIDS DM P 221 o , (ML W/ LESS THAN 10% WATER), NA 2 W 3 4 14.Speaa.Handing Instructions and Additional Information TSD fi W I 84738702 AD30642 CSG: 2M EMERSENCY#8eO-468-1760-CH/SK/TFI-Contrast retained by generator confers a engy authori y on initial transcorter to add or substitute additionalr rt r en ff] ' 15. GENERATOR'S10FFEROR'5 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 labelecilplacarded,and are in all respects in proper condition far transport according to applicable intemational 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 EPAAcknowledgment of Consent. I certity that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(d I am a small quantity generator)is true. Genera Offerors Prinledrryped Name Signature . Month Day Year 18.International Shipments VF ❑Import to U.S. ❑Exp6rt from U S. Port of entrylexit: ? Transporter signature(for exports only): Date lea,nng U.S.: IX W 17.TrensporterAdmowledgment of Receipt of Materials Transporter 1 Pdntedffyped Name Signature Month Day Year 0 LLL kTransporte0 PrinWgyped Name Signature ( Month Day Year F �,J 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Dull Rejection Manifest Reference Number. 18b.Altemale Facility(or Generator) U.S.EPA ID Number J V tai Facility's Phone: w 18c.Signature of Altemate Facility(or Generator) Month Day Year a Z ILD 19.Hazardous Waste Report Management Method Codes(i.a,.oodes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3 4. 20.Designated Facility Owner or Operator;Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPL� 487i822 Rev.12-17 Previous editions are obsolete. GENERATOR'S INITIAL COPY