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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAR000225557 800-556-9090020623089 JJ K <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> YRC Inc. dba YRC Freight <br /> 10990 Roe Ave. Overland Park, KS 66211 1535 E Pescadero Ave <br /> Generators Phone: 913-344-5205 - Tracy, CA 95304 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Ancon Marine CAD980737068 <br /> 7.Transpoq r 2 Company Name U.S.EPA ID Number <br /> LLC 0 <br /> 8.Designated Facility Name and Site Addr ss U.S.EPA ID Number <br /> Crosby&Overton <br /> 1630 W. 17th St.- Long Beach, CA 90813 <br /> Facility's Phone: (5621432-5445 28409019 <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> o ' Non-RCRA Hazardous Waste Solid(Debris, Neutralized 181 <br /> Hydrobromic Acid) 2 DF 250 P <br /> Z 2. <br /> w <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1.ERG 171 Debris 2x558 Profiler 118389 <br /> ERG Book I,V.hic1.:Wow prow r, L ci <br /> osHA approved PFE When hwdfing t v <br /> nuftrkk on aa.nwife.c Job# 400.13.28539 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,art 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 /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity gen rator)or(b)(III am a small quanlily generator)is true. <br /> GvtoeslOfferors Pri !Typed Vame" Sign fur M D �Year <br /> � <br /> �IIfAAVVVV V <br /> 16.International Shipments <br /> El imprt o U.S. Ll Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLJ <br /> Trans r 1 Prinled/Typed Na a Si ure Month Day Year <br /> re <br /> O O <br /> 0 <br /> Q Tra e 2 Printed ped a Mont Day Year <br /> ; /� C/ 11 Iry <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑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 /> 0 Facility's Phone: Month Day Year <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> a <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1' �& V/ <br /> `/ 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of haisirclous mate Is co erect by the manifest except as noted In Item 18a <br /> PrintedrTyped Nme / Signature Mon}tL Year <br /> EPA Form 6700-22(Rev.12-r) Previous editions are obsolete. DESIGNATED FAC TY TO EPA's e-MANIFEST SYSTEM <br />