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/ NON-HAZAROOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> r <br /> WASTE MANIFEST - _624- 26 WR - <br /> N 5.Generator's Name and Mailing Address Att_Traci Rohde Generators Site Address(if different than mailing address) <br /> Union Pacific Railroad Union Pacific Railroad <br /> `- 301 NE 2nd Ave 833 East 8th St. <br /> Portland OR 97232 Stockton CA 95206 <br /> Generator's Phone: <br /> 1 6.Transporter 1 Company ame68 U.S.EPA ID Number <br /> Patriot EnvironmentalSer-vicesr <br /> 1 7.Transporter 2 Company Name U.S.EPA ID Number <br /> V <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> • Waste Connections-Potrero Hills Landfill <br /> 3675 Potrero Hills Lane <br /> ' Suisun City_ CA 94585 <br /> Facili 's Phone:7n7 432-4527 <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description <br /> y No. Type Quantity WUV01. <br /> a <br /> cc iVon-Hazardous V�bste,Solid(Soil with Diesel Fuel) <br /> � c X <br /> c� Joao <br /> WDM P <br /> z 2. <br /> c ry <br /> a` C7 <br /> E <br /> 0 <br /> � 3. <br /> m <br /> m 4. <br /> r; <br /> N <br /> _ 8 <br /> 13.Special Handling Instructions and Additional Information <br /> N 1)ERG#153"`R#19721 Job No. 11-19-00013 Profile#PHLF- -V3 ) <br /> _ 3 <br /> A <br /> Z ro ✓ �E <br /> 0 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents gYM a f g e Ii�Qr l� pi and are classified,packagr <br /> marked and labeled/placarded,and are in all respect in pr per TgZion for tr sport applicable intemati al and na' al govemmenta tions. <br /> Genera r eror' Pnnted/ <br /> U Ty d St Month Day <br /> a p <br /> J 15.I tem ional ipmenis <br /> aA�*,nra <br /> U) <br /> ❑Import to U.S. ❑Export from U.S. Port of entry exit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> w <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> Y LU <br /> Transporter 1 Printed/Typed NaW Signature Month Day <br /> S Ivy ,�-►ti'r � � Q5' , <br /> I� o z Transporter 2 Printed/Typed Name Signature Month Day <br /> � H <br /> H <br /> a 17.Discrepancy <br /> 17a,Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejectk <br /> Manifest Reference Number: <br /> r 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ua Facility's Phone: <br /> 17c Signature of Alternate Facility(or Generator) Month Day <br /> z <br /> z <br /> U1 <br /> W <br /> I18.Designated Facility Owner or Operator:Certification of r kipt of terials covered by the manifest except as noted in Item 17 <br /> Prinledrfyped Name Signature <br /> IND I � ), )l J1 <br /> 169-BLC-0 5 11977(Rev.9/09) DESIGNATED FACILITY TOG RI <br />