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Please print or lype. Form Approved. OMB No. 2050-0039 GENERATOR o• I UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number CAC003161419 2. Page 1 of 1 3. Emergency Response Phone 800-556-9090 4. Manifest Tracking Number 0 2 3 2 9 5190 JJK Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Schneider National 3101 S. Packerland Dr Green Bay, WI 54313 1-5 at 8 Mile Rd Generator's Phone: 920-592-2000 - 1 Stockton, CA 95209 Transporter 1 Company Name U.S. EPA ID Number Ancon Marine I . CAD980737068 Tran ra t4e;12)Com S. any Name , U.S. EPA ID Number ', Ov444ti .L4Ar I OA-) l_i-ctUqc,(9 Designated Facility Na) and Site Address U.S. EPA ID Num er Crosby & Overton 1630 W. 17th St. - Long Beach, CA 90813 Facility's Phone: (562) 432-5445 I CADQ28409019 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers . 11. Total 12. Unit 13. Waste Codes Hm and Packing Group (if any)) No. Type Quantity WIA/ol. 1. Non-RCRA Hazardous Waste Solid (Diesel, Debris) i 3 352 -20- DM 3500 p 2. 3. 4, 14i SgAtHfilin tis Instructions 2 and l Additional Information 63114 n 1,, ERT8 AL21045105 IR41 look In Vehicle: Vim met OSHA approved PPE When Mong Si. man& on I* male& Job# 400.13.36612 GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ant are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) Is true. Generator's • em rinted/Typed Name Signature Month Day Year 12eldetki- al I 81 22_ I 00 04- 54nticier ,d ,ttiv4W _, F- International Shipments Import to U.S. Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: Transporter Acknowledgment of Receipt of Materials TRANSPORTE Trans.. rter 1 Printed/Typed Nam- ,. i . ..,,•%, Signature Month Day Year -!... Pr / I 5.eiv-e picti9we._ I Tra 411.. er rintedrfypeAame it_._ 14 4,k7,6-0-rvbc6 1 Signature Month Day Year 10_1/ P• 12-2- DESIGNATED FACILITY -> Discrepancy 18a. Discrepancy Indication Space III Quantity LI Type Residue 111111 Partial Rejection Full Rejection Manifest Reference Number: 18b, Alternate Facility (or Generator) U.S. EPA ID NuMber Facility's Phone: I 18c. Signature of Alternate Facility (or Generator) Month Day Year I I Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1.H ILI-1 2. 3. 4. . 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest ex t as nded in Item .18a Printed /Tv Af ped Name Signature Month Day Year S. c (CI Lop-u- 1 1 9- I'3 IN- EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYS