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0 9 <br /> Plea se print or lype.(Form designed for use on elite(12-pitch)typewritec)MG001075y7 Sr i3P l 1/�OI201b' Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator lD Number 2.Page t of J.Emergency Response Phone 4.Manliest Tracking Number - <br /> WASTE MANIFEST CAR 0 O O F 2 5 1 5 7 'J, S00'42T M x,8 0 FLE <br /> 5.Genemtars Name and MailiNAddress Generators SileAddress(ti difierenf than masng address) <br /> YRC Ina d.b.aYRC Freight <br /> 109.90 Rrlp AVP <br /> Overland Park p($662i i j53fEaa� 0� .rjarD Ewa j <br /> Generators Phone: non ATTU-IlArvoip _ j}a i_p 951SU4. <br /> 6.Ti pater t Company Name U.S.EPA ID Number <br /> Clean Harbors Environmental Sersice,ine. A <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> S.Designated Fadity Name and SiteAddress <br /> Clean Harbors San Jose LLC U.S.EPAID Number <br /> 102i Berryessa Road <br /> ��je. G 61 D O x 9 4 9 4 3 10 <br /> Fac CA 95133 <br /> ga, 9b.U.S.DOT Descdptfcn(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Gmup(ifOgf) i1.Total 12.Unk 13 Wast <br /> No. Type Quantity WtNoL Waste Codes <br /> 1. <br /> ocUN21300,BATTERIES.`NET.NON-Bp}LLAT LE,i�,(UNIVERSAL r <br /> w <br /> x WASTE-BATTERIES) �� 150 P <br /> W 2. <br /> 3. <br /> 4. <br /> 14.Special Handling InsWcBons and Additional Infomedon <br /> ,1.CH1126046 ERGI#254 jxs4bF #JOB 33525 <br /> €J 160 0M;WSJ, <br /> 15. GENERATORSIOFFEROR'SCERTIFICATION: I hereby declare thatme commis of this consignmentarefully and accurately described above by the pmpershiping come,andare classified,packaged, <br /> marked and kbeleEfplerarded,andam in allraspecls in properconditionfortmamporimmrfing to appficableintemattonal aid nationalgovemmened regulations.ltexpmtshipmenland la ePdmary <br /> Exporter,I certlyihat the contentsofWsconsignmentconfmm to Beterms ofNeaflached EPAAdmaMme mentofGomeaL <br /> 1 ceNly that the waste minimization statement identified in 40 CFR26227(a)(jif I am a large quantity generates)or(h)lif I am a small quantity generator)is true. <br /> UenemdorV.Ctapops PtintediTyped Name gnal�ure/ ` Month Day yyear� I <br /> _r 18.International Shpmems <br /> Z ❑lmponlo US. LJ Export from U.S. Po4olenayyexi: <br /> Transporter si nature for uports only): Dak leaven U.S.: t� <br /> W 17.TmnspoderAckrwwledgrnwtolRece4tafMatedals <br /> o Tronspfor)ear—1 Pdnledlfyped N e <br /> 8[no ure on-Linay9 e/ar <br /> 49 <br /> 6-7 <br /> a Transporter Panled/lyped Name SignaNre rdonth Day Year <br /> A. is.Discrepancy <br /> 18a.Discrepancy Indicallon Space ❑ Quantity ❑Type YP El Residue ❑Partial Rejedion ❑FM Rejection <br /> Manifest <br /> 181h.Alternate FacilityReferenceNumber:(or Generator) U.S.FPAID Number <br /> J <br /> U <br /> LL Fec� SPlwne: <br /> w TBC Signature MAlfemate Facility(a Generator) Mmdh Day Year <br /> Z <br /> N19.Hazardous Waste ReportMaregement Method Codes p.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1' H 141 z 3. 4. <br /> 20,Designated Facility Owners Cpemtor.Cerii icetion of recelplof hazardous mafedaLa oavored by the manifest except as noted in Item 18a <br /> Prtlmd/fyped Name at <br /> Month Day Year <br /> EPA Formffianw %dtS%as Lorjdjpnjff8&V1%iig for and will arpept the waste TO DESTINATION STATE(IF REQUIRED) <br />