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N <br /> • QTSC. 03601 . 209• <br /> Please print or type.(Form designed for use on elite(12-pitch)t 2ewfiter.)71 1600107517 SC PPW 1/20/2016 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I.Generator Number 2.Paget of 3.EmergencyResponse Phone 4.Manifest Tracking Number FLE <br /> WASTE MANIFEST CAR 0 0 0 2 2 5 5 5 7L 1 800 4833718 <br /> 5.Generators Name and Mailing Address Geneators Site Address(it different man mailing address) <br /> YRC Inc d.b.aYRC Fre'W,M <br /> 10990 Rne,Ave, 1535 East Pescader0 AYe <br /> Overland Park,KS 85211 Tracr,CA 95304 <br /> Generators Phone U.S.EPA IO Number <br /> 6.Transported company Name <br /> Clean Harbors Environmental Service.Inc <br /> 7,Tmnsponer 2 Company Name U S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Harbors San Jose LLC CAD 0 5 9 4 9 4 3 1 0 <br /> 102k1 nBerrYessa Road <br /> FadlitG�ar5 40%.e.CA 95133 <br /> ga 96.U.S.COT Decripton QnUuding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Tietal 12.Unit 13.Waste Codes <br /> HM and Packing Group(q any)) No. Type Quantity WtNDI. <br /> 0 1 U N2800.BATTERIES.WET.NONSPILLABLE.B,(IJ NIYERSAL <br /> Of bF 150 <br /> WASTE-BATTERIESJ <br /> z z. <br /> w <br /> O <br /> 3. <br /> 4. <br /> 14.Special Handling mswdions and additional Information (XSSO #JOB 33515 <br /> 1_CH1126046 ERC,lY154 <br /> 69-160 0/0 75d <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am fully and accurately desvibed above by the proper shipping name,and are classified packaged, <br /> marked and labeled/placarded,and are in all iespeds in proper condition for transport according to applicable International and national governmental regulations.If export shipment and I am the Primary <br /> Exporter.I cemiy that the contents of this consignment conform to the terns of the attached EPA Ackne ledgment of Consent <br /> I ceNy that the waste minimization statement identified in 40 CFR 262.27(x)IN I am a large elumd ge annDr)or(b)(if I am a small quantity generator)is true. on ay Year <br /> eneator s dnt yp Name tgna re <br /> S'ru e- ,L &A q � A <br /> —a 16.International Shipment ❑Import to US ❑Exponfrom U.S. Pall of emylexit <br /> Zlea <br /> — <br /> Transporter signature for experts on Date vm U.S.: <br /> W <br /> 17.TansporterAcknoeledgment of Receipt of Materials n ay ear <br /> Transpoper 1 nnteQRyped N e r 0� <br /> O l{t�rc <br /> Z Transposer 2 PdnledRyPW Name Signature on ay ear <br /> 6 <br /> C <br /> x- <br /> t18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ mangy Typo L1 Residue ElPartial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> U.S.EPA ID Number <br /> I8b.NteFacultyate Faculty(a Generator) <br /> 7 <br /> V <br /> LL Fad sPhone: Month Day Year <br /> W 18c.SignaWre olA Wren Fadiy ner <br /> (or Geator) <br /> a <br /> z <br /> 19.Harardws Waste Report Management McOrod Codes(i.e.,nodes for hazardous waste beabnent disposal,and recycling system) <br /> G I H141 2 <br /> 3. r- <br /> 20.Denigrated Fao1Ay Omeror Opeatw Certlfmaltm of[erupt of=rdws matena'aoovzred by the mandest exceptasratedin Item183 Month Day Yezr, <br /> 1 Name Sgna <br /> EPA Forth&je2nli8rpo�rS 0aSe111PS2DU rte�o�efils for and will aceept the waste the Eenc9 _LITY TO DESTINATION STATE(IF REQUIRED) <br /> x. 12252.0791 <br />