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DTSC. 03420. 1609 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewnter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST IQ A r In n 2 R NRC 510.749.1390 014380358 JJ K <br /> 5.Generators Name and Marling Address At MERILYN BEWNDER Genemto's Site Address(if different than nailing address) <br /> BNSF RAILWAY COMPANY BNSF RAIWAY COMPANY <br /> 740 E CARNEGIE DR STOCKTON SUBDIVISION MP111g.5 TRACK 139 <br /> SAN BERNANDINO CA 92408 STOCKTON CA 95200 <br /> Generators Phone: <br /> S.Imrsponer 1 Company ame U.S.EPA ID Number <br /> NRC ENVIRONMENTAL SERVICES INC. IC A R 0 0 0 0 3 0 1 1 4 <br /> 7.Tansporta 2 Company C u.s.EPA ID Number <br /> irf'- � �'r C F/fVAdn71A �lj/ <br /> 8.Designated Facliy,Name and Ste Address U.S.EPA ID Number <br /> Filter Recycling Services <br /> 180 W.Monte Ave. <br /> Rialto CA 92310 <br /> Facilites Phone' <br /> go9b.U.S.COT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(it any)) No. Type Ouanliry WtNol. <br /> c 1JN3077,ENVIRONMENTAL HAZARDOUS SUBSTANCES,SOLID, .33 <br /> X N.O.S.,(DEBRIS,SODIUM METHYLDITHIOCARBAMATE),9,III Q1UQ <br /> w if <br /> z 2. <br /> w <br /> e7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> WEAR PROPER PER30NAL PROTECTIVE EQUIPMENT; JOB/PO#. <br /> NRC ENVIROMMNTAL 4EAVICE3: 1605 FERRY POINT, ALAMEDA, CA 04501 � <br /> 981) PROFILE# 15090106, 2x55G <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by Me proper shipping name,and are classified,packaged, <br /> marked and Iateeledcerd <br /> /plaed,and are in all respects in proper condition for transport according to applicable international aid national govemmenal regulations.If export shipment and I am the Primary <br /> Exporter,I cerefy that the contents of this consignment conform to the terms of the attached EPAAckrowledgment of Consent. <br /> I miry that the waste minimization statement identified in 40 CFR 262.27(a)(i(I am a large quantity generator)or(b)(dl am a firnal uantiry generator)is We. <br /> Generators/Offerors Pnnted/Typed Namo (/s)/f Signature Mgc(h Day Year <br /> �r )/� 7 t s <br /> F 16.InternalShipments ❑Importto U.S. ❑Expert from U.s. Port of entry/exit: <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Tmnsporter Aclmov.4edgmer9of Reoeiptut Materials <br /> Transporter 1 Pnnted7Typed Name Signature Month Cay Year <br /> did <br /> l4az cC Gvl <br /> GTrensparter2 Pnnted/f c-0N`meSignature Month Day Year <br /> 4. 18.Discrepancy <br /> 18a.Discrepancy Indication Spare ,y ❑T ❑Partial Re ❑Full Rejection <br /> ❑ Ouanti� Type El Rejection 1 <br /> Manifest Reference Number <br /> 18b,ARemate Facility(or Generator) U.S.EPA 10 Number <br /> J <br /> U <br /> LL Fadfitys Phone: <br /> w 18c.Signature ofAltemale Fadry,(w Generator) Month Day Year <br /> t- <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes fix-,codes for hazardous wast treatment,disposal,and recycling systems) <br /> � 1. '12. 3. 4. <br /> 20,Designated F-ala'tityyO«ner or Operator Certification of receipt of hazardous malenals covered by the ma az tem 18a <br /> Il Pnnted/Typed Name Sig t D Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br /> 12177.1818 <br />