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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 800-556-9090 020623089 JJ K <br /> II 5.Generators 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: 913-344-6205 - Tracy, CA 95304 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Ancon Marine CAD980737068 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> L_6 ~j�/r�.t� ' pLLL-C ) 1 l L <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: 562 432-5445 <br /> 9a 9b.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 /> w <br /> Z z. <br /> w <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1.ERG 171 Debris 2x558 PrOW 118389 <br /> I:aa 6odc In v.ttta.:Wear proper <br /> OSHA mpproved PPE whrn h.,diino fix <br /> matrWsonttbnu ff"t. 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,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable inlemationaland national governmental regu`ations.If export shpment 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 ator)or(b)(if I am a small quantity generator)is true. <br /> G netalor's/Offerors Pri yped ame" Sign lur M D /Y]earr� <br /> /4 'VAV�V V !�/ <br /> ,1 16.International Shipments <br /> i:- ❑Im rot <br /> o U.S. Export from U.S. Port of entry/exit: -__- <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLI <br /> Trans er 1 Pnnted/Typed Na a Si ure Month Day Year <br /> O <br /> r°n G Month Da Year <br /> Z Tra e 2 Pr nle d No% <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 /> uQ Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. �� ` 2. 3. 4. <br /> I20.Designated Facility Owner or Operator:Certification of receipt of he rdous mate Is co ered by the manifest except as noted in Item 18a <br /> -L)IM110/I � I\ 'Printedrryped Nme - Signature Mone Day Year <br /> EPA Form 8700-22(Rev.1 ) Previous editions are obsolete. DESIGNATED FAC TY TO EPA's e-MANIFEST SYSTEM <br />