Laserfiche WebLink
f <br /> -Please print of type. +'= Form Approved.OMB No.2050-0039' <br /> i. UNIFORM HAZARDOUS 1-Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Ndmbx <br /> i WASTE MANIFEST IC� A D 9 S 2 0 3 0 2 0 ! :=x8$77-7267 �ID 19 7 0 3 8 0 5 JJ K <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> UHOTI Pactrta Eaiira3fj Urnior PaciTtc R'aiiroad <br /> *3520 Corporate Ger e33 East 13th St. <br /> indianapolis It.i 45278 ` Stockton Gig 85206 <br /> Generators Phone: ?3 1 SAE+ 9 0 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Pathot Ena-jrorrmental Services C A D 0 5 3 8 5 6 7 3 4 <br /> ( N <br /> n <br /> 2 C <br /> t <br /> 7.Transporter ompay ame <br /> i eceive�S.EPA ID Number <br /> 1 8.Designated Facility Name and Site Address- NO V 2 3 20V.EPA ID Number <br /> f GkrerriaaiMaragement,;rtc.Kettiet-rian link � <br /> J<etderrc4nHillsL.DFLHighvey#9 — 3SR5/ D/� S '/ GHD <br /> INDIANAPO <br /> Facility's Phone:559 380-0711 IS AT 0 Q D B 4 6 7 i 7 . <br /> I ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Pacidng Group(if any)) No. I Type Quantity Wt1Vol.- <br /> Qa1:4SGI64 6117 <br /> 8TESEt•'�C A► ►—�I 'tr A � LiS 1 ` <br /> ofI-- <br /> :;_11 2. <br /> I „ w <br /> i <br /> i <br /> 3 <br /> r <br /> t <br /> I 14.Special Handling Instructions andAddidaral Information ^ Qr ' <br /> J# 11-20-0,044 ., ,; o 3 `r �C 1 < <br /> P# CA619 012 ,,� 44 t� �� a 4 <br /> Ii3R#2 D 8 0 Alasray{s wear appf-opriate PPE wI'if:n handing waste-,OB# <br /> i 15. GENERATOR'SfOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations.If export shipment aPd I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of ConseriE <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)Cif I am a large quantity generator)or(b)(fl am a small quantity generator)is true. " <br /> GeneratoeslOfferor's Pdntedrryped Name Signature Month Day Year <br /> ��rl`"_lc! UPPR DEREK SMITH <br /> -j 16.International Shipments <br /> r— ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> g 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedlryped Name Signature ,moo Month Day Year <br /> a STEVE EPQW4 <br /> Z Transporter 2 Printed/Typed Name Signature Mordh Dry Year <br /> t— <br /> •18.Discrepancy <br /> 16a Discrepancylndication Space" <br /> 1:1 Quantity,1 ❑Type :u. ❑Residue ❑Partial'Rejection EJ Full Rejection <br /> Manifest Reference Number, <br /> 1 18b.AlternateFacility(or Generator) U.S.EPA ID Number <br /> i.. V <br /> ua Facility's Phone: <br /> wm <br /> 180.Signature of Alternate Facility(or Generator) Month Day' Year <br /> E a . <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes C-e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ 0 1 2. 3. 4. <br /> 20"pesignMed Facility Owner or-Operator..CertificaL•on otreceiptofl)azardous,matedals.pouefeihythe.manifestogcoptas,pded n_Item;Ba-•,• .".:z..":_.y.....• ..•_....._.._:.._y._K..:-.•--_ <br /> i <br /> Printed/Typed Name Signature Madh Day Year <br /> I. <br /> EPA Form 8700-22(Rev.12-17) Previous editions re obsolete. I ESIGNATED FACILITY TO GENERATOR <br /> , <br />