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0„ <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 <br /> 1.Generator to Number Z.Page 1 10f 3.Emergency Response Phone 4.Manifest Tracking Number C C <br /> WASTE MANIFEST . r - er. _ f LC <br /> Gemmto/s Nameand Mailim7 res5 Generators e Address(it tlillemnl Nan malslg fess) <br /> Attn:Jamle Hain" <br /> YRC Inc. d.b.a. YRC freight 7?P Rs^;dawap <br /> 913-344-5205 1C"990 Ree Ave3233 LDoo1s mGeneramYs Phone: <br /> mreporer 1 ny NameQuoll r PA ID Nu <br /> n <br /> 11 <br /> 7.Transparter2CompanyN <br /> e.Designated Farbty Name are de Address Clean Bsrbare San Jose, LW U.S.EPA ID Number <br /> 1021 Berryessa Read <br /> San Jose. CA ?5133 <br /> Fear sPtare: r 1 _r '7 O = •1 <br /> qe 96.U.S.DOT DeScnpAm intludmg Proper Shipping Name,Hazard Class.10 Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Ping Grail(M any)) No. Type Quantity ".No1. <br /> � ' R 1[kt3175, Neste Solids containing flaem>dbl= ileuld, n.v.s. 1i 352 Pre CCR,5 <br /> (Toluene, xylene), 4.1, PG II <br /> P M <br /> Z 2. <br /> W <br /> !3 <br /> 3. <br /> 4. <br /> 14.special Handling Instructions and Additcral information I.CB8u4014 PR0P525--4455915 (1x15! 1AIKS-1v1, `//Iq2—I 757 712-0,zgU <br /> RHI Job #33322 <br /> 15.. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare Met me contents of Nis"sgnment was fully and accurately described stove by Me Proper sapping name,and are classified,packaged, <br /> marked and labeladlplecarded,and are in all respects in proper condition for Uanspon according to a0cable inlemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I wrfiry Nal me contents of this demgnment conform to the terms of he attached EPA Ankrro nazn of Consent <br /> I certify mat the waste mansumsMon statement identified in 40 CFR 262.27(a)(M I am a large gwnMfy geriersta)or(b)(if I am a small quantty generator)is true. <br /> 7��rroesin a - a u aay Year <br /> tl� lie 17 1/3 <br /> .ui16.Inlematlamal Shipments <br /> F— ❑import to U.S. ❑6port ban U.S.. Pad of eniryfexk: ._. <br /> z Transporter Signet" for exports only): Data laving U.S.: <br /> 17.TmreporlerPrlaroadedgmnem of Receipt of Manstals kilorth pay Year <br /> miraboderl rmtedfryyad <br /> Q TranspDre,2 PnntedfTyped Name signumarnaw <br /> jS.Discrepa <br /> 1 as.Discrepancy Indication Space El Quantity ❑Type EJResidue ❑Partial Rejection ❑Fag Rated. <br /> Manifest Reference Number: <br /> 10b.Allema a Facility(a Genemla) U.S.EPA to Number <br /> J <br /> U <br /> LL Fadi' sPMrc: <br /> W 18c.Signabxe afAMernale Fa:ifly(a Generator) Maim Day Year <br /> 4 <br /> z <br /> N19.Hwwdous Waste Report Management Memod Codas(i.e.,axles for hazardous waste baahent,disposal.and mcycmV systems) <br /> 2. 3, 4, <br /> 20.Desgnated F 0ional Operator.Certificatlon of receipt of hazardous Miami$mvered by Ne manifest except as noted in Item IBe <br /> Pmi yped Name S' attar th Dqn Year <br /> EPAOD-22 .3-05) Previous editions are obsolee. ESIGNA D FAclOrryTO G&ERrDR <br />