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INT'L t GENERATOR 0 I NON-HAZARDOUS <br />WASTE MANIFEST <br />1, Generator ID Number <br />C.: ,:"1:.D0 92 0 3 0 2 0 7 <br />2 Page 1 of <br />i <br />3. Emergency Response Phone <br />9'33-87"i-7267 <br />4. Waste Tracking Number <br />1 2 2 0 2 0 6 0 5 1 <br />Generator's Name and Mailing Address At: Menifes-t Receiving Generator's Site Address lit different than mailing address) <br />Union Pacific Railroad oto GHD Union Pacific "Railroad <br />8520 Corporate Dr. 833 E 8th Street <br />Indtariscdfis IN 45278 1 Stockton CA J5206 <br />Generator's Phone: 01 6 540- 0405 I <br />Transporter 1 Company Name U.S. EPA ID Number <br />.4,merican Integrated Services, Inc. 'CARO 0 0 1 4 8 3 3 6 <br />7 Tra9sporier 2 Co pony <br />et trjaleVi <br /> <br />Name U.S. EPA ID Number <br /> <br />7 0 \I .c-vfm, Lt le I CAV)9.--s'-ctacie) tri <br />B Designated Facility. Neie and Site Address <br />Gros-by & Overton, inc. <br />I HO W. -17th Street <br />Long Seach CA 00813 <br />Facirdys Phone. 562 422-5445 <br />U.S. EPA ID Number <br />CADO 2840 9 0 1 9 <br />10. Containers 11. Total 12. Unit <br />9. Waste Shipping Name and Description No Type Quantity Wt.Not <br />Non-Hazardous Waste, Solid (Oil and Debris) <br />0 0 1 DM WO <br />13, Special Handling Instructions and Additional Information <br />Alwye We=r Approprizte PPE when h=ndling wzete. Weigh-or( or volume zsre ..arproximare. <br />1_ Profile Number: 11.762 A15 acJb Number:79020-117 Tal#2522 <br />tqt-eLi <br />14. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents at airs consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br />Generators/Offerors Printed/Typed Name Signature Month Day Year <br />Mielynda Borreao on behalf of UPRR I N e I 12, I 1t, I 20 <br />15. Intemational Shipments Export from U S. Port of entry/exit <br />, <br />Import to U.S. <br />Date leaving U.S.: Transporter Signature (for exports only): <br />16. Transporter Acknowledgment of Receipt of Materials TRANSPORTER Transporter I Printed/Typed Name Signature401/1Fp Month Day Year <br />---1.0 1'--'"/'RI 5'--"--- I (2-1 16-1 2 0 'I <br />Tm rte Printed/Typed Name Signatu 7 <br />,t_C,L_ Lk 0 1-t4.1...f-t., /L-. 34...4 ' I <br />Month Day Year <br />i '14 tu I DESIGNATED FACILITY 17. Discrepancy <br />17a Discreppncy Indication Space <br />Quantity Type Residue Partial Rejection Full Rejection <br />Manifest Reference Number: ., <br />17b Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: I ,.•' <br />17c Signature of Alternate Facility (or Generator) Month Day Year <br />......8 i (.. f i <br />: <br />,,--` <br />18. Designated Facility Owner or Operator: Certification of eceipt of rtalS covered by the manifest except as noted in kern 17a <br />PrintediTyped a p6,- mok...._ - / <br />-----.. <br />Signature Day r Yet,- <br />( <br />DESIGNATED FACILITY TO GENERATOR 169-BLC-0 5 11977 (Rev. 9/09)