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Please print or type.(Form designed for use on elite(12-pitch)typewriter)7)1500107517 'SC PPW 1/20/2016 Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Pagel of 3.Emergency Response Phone O.Manifest Tracking Number C WASTE MANIFEST CAR 0 0 0 2 2 5 5 5 7 �. 800)493-3718 O )8936 r C LG 5.Generators Name and Mailing Address Generalors Sire Address(d different than mating address) YRC Inc d.b.a YRC Freight 10990 Rnp Auto 1x+35 F85.Pei �e(:s awe Overland Park I(S 66211 Generators Plane: _ I racv,CA 95-U4 6. rranspoMr 1 ompany amt U.S.EPA ID Number Clean Harbors Environmental Service.Ino. 50 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPAID Number Clean Harbors San Jose LLC 1021 Berrvessa Road A D 0 5 9 4 9 4 3 10 Fa 4pf.e.CA 95133 9a, gb.U.S.DOT Desciptlon Including Proper Shipping Name,Hazard Class,ID Number, 10.Coneiners HM and PackingNo. Type Quantity WtNd. Packing Group(if any)) 11.Total 12.Uri. 13.Waste Codes UN2800.BATTERIES, 1. x WASTE BATTER ES} 4YE7.NON SPILLABLE,8,(UNIVERSAL 0 1 bF 150 i� I z 2. w c7 3. F 4. ENVIR NMEN PE IT/SE VICES 14.Special Handling Instructions and Additional lnfomtatirm ,1.CH1126046 EF #9G8 33515G#154 ,S OF el-160 oto 751� 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, marked and labeled/plaardei,and as in an respects in proper condition for transport according to applicable intemational and national governmental regulations.It erpon shipment and I arrijbip Primary Eaponer,I certify that he contents of this consignment conform to the terms of he attached EPAAcknowiedgment of Consent I certify that the waste minimization statement identified in 40 CFR 252.27(a)(t I am a large quantity generator)or(b)(f I am a small quantity generator)is true. Genemto n typed Name blignature j ear -I-rr q rn� jl:/ J 16.International SNpme its Z Transporter signature for oM El Import to U.S. LJ Export from U.S. Pot of enbyla t f Dale leave U.S.: W 17.TzanspcnerAcknceledgment ofRemip.afMaterials QTransco er 1 Pnntedffyped N e Igoe re nl ay ear Gd a w. � 09-11n /6 Transport 2 PnntedRyped Name Signature ooh Day Year F- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑T e yp F-1 Residue ❑Partial Rejection ❑Full Rejector Manifest Relemnes Number. F 18b.Alternate Faciiry(or Generator) U.S.EPA 10 Number J U Q h'- Faclli a Phone: w 18c.Signature of Alternate Facility(a Generator) Month Day Year Q z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for haamoa sumste treatment,disposal,and recycling systems) 1 H:1412. 3. 4. 20.Designated FaciGry,Owneror Operator:Certification M receiptof hazardous materials covered by he manifest eirrol as noted in Item fee VIII' Prnted/ryped Name �3--oosl bis Signature PlInNh Day Yea: EPA FortnClBBnliarlJtlr3 na�et�l°LY app�osyt°e p°>'•etrinits for and will at; ihr.Wasie the afencqE {PPB! LITY TO DESTINATION STATE(IF REQUIRED;