|
Please print or type. Form Approved. OMB No. 2050-0039 ' GENERATOR ( I UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1. Generator ID Number
<br />CA.00 00g 8 I 7 7'2
<br />2. Page 1 of
<br />,
<br />3. Emergency Response Phone
<br />2-S87-7207
<br />4. Manifest Track i4 Number
<br />019 / 0 3 3 0 6 „WI(
<br />Generator's Name and Mailing Addiess Pilt -nmEr,..?,krror, Generator's Site Address (if different than mailing address)
<br />Union PacItio F.Efil Roao Union Paciilo RwIroaci 0520 CORPORATE RD 1000 E ROTH RD
<br />INUA.NAPOUS iN 48278 FRENCH CAMP c-::Ls' gt.'.2i3i
<br />Generator's Phone I
<br />Transporter 1 Company Name U.S. EPA ID Number
<br />Patriot Environmental .!.3ervirs Received ICAD05 3 8 8 8 7 g 4
<br />Tran,siorter 2 Company Name U.S. EPA ID Number
<br />(:,) lik / 41-V1 L,, -e , ,,, FFR 1-5 2021 1
<br />gnated Faciaty.
<br />m
<br />e and Site Address U.S. EPA ID Number Qa
<br />1830,
<br />Long
<br />Facilit
<br />(.-rosDay
<br />13
<br />
<br />8,1,...Pv non
<br />W 17th St7.,:-.,-t GHD
<br />Beach CA G0813 Indianapolis
<br />
<br />r's Phone:562 432-5445 1 C A D 0 2 8 4 0 Q 0 1 .8
<br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes HMand Packing Group (if any)) No. Type Quantity WtNol.
<br />tiON-RCRA HAZARDOUS WASTE, tiQUiD 223
<br />(0ii2-1 lifkAT'ER. ..). DM LO c
<br />, ;.sPoskt... TREA --'t wAs KCCEIVED. HA, 4<,,,,,n_s ,..,... _ oR keusE. cRosa y - ----r-u AND Mita) Tu .vnli lifE,-71,,,,IED That By 1.1. _ & 0 van.° N iivc l'OR SUElsEctevr tNVIRom,,EENTAL _ rdEPAR-rwiDrr oF -,„ ' °P8RATES TRE ri-CE RESOURcE cow ,_ .. ,AOTEC•noN A. GEN,_,, 4 ,-/XIC SIJBSTA NCE FAClury °FeSr11 ulkinep
<br />'3 i : n C fu ‘CCOrtuANCE Cn-r,,..1'11°L 3? Al_ "wit, n.Arr'ATIO" .'..1,43 gLcovEi; likEnIEF ''ERMIT3 TO AccEpr -REGULATIONS. cRosBy .ACT °F 1976 TGG - • n.OVISJONS OF ."-T1RODioLy 1 IQ REFERENCED 'ANC)DVIERT" wAsTE HAS ALL or wri/1._ AMICABLE
<br />MEE WASTE las ' '' NE
<br />FLANna
<br />-S SARy
<br />.-14 _____
<br />Special Handling Instructions and Additional Information
<br />PROFILE - 1i722. .
<br />WR# 0026&8. - .1
<br />J# 11-20-006.n Always wear appropriate PPE wtaen handlinq waste. JOB# -
<br />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, ard 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. If export shipment and I are the Primary.
<br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowleWentof .nsent.
<br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity genetator)..orsy I am /Oa!l guantity generator) is true.
<br />Generators/Offeror's Printed/Typed Name . Signatur Month Day Year
<br />. BO LiPRR ..."1::),..-Tr,.._ O 111.k
<br />_i 16,Intemational Shipments Import to U.S. Export from U.S Porrof-er+try13exit:
<br />Transporter signature (for exports only): Date leaving U.S.:
<br />i.:5 17. TransporterAcknowledgment of Receipt of Materials N .. TRANSPORTE 'Transporter 1 Printed/Typed Name
<br />ign DEREK SkeliTH I atr
<br />Month Day Year
<br />1, I-7-4
<br />
<br />Transporter 2 Pnnted/Typed,,,Uwo.-,..._ , Signatu .......... Month Day Year
<br />
<br />P,IiiR.F-J4-SivtiT44---.) 1/C' V ... 144 IA kItt,t. 4-1- DESIGNATED FACILITY -0.1 18. Discrepancy
<br />Discrepancy Indication Space El 6uantity El Type El Residue Partial Rejection Full Rejection
<br />,
<br />Manifest Reference Number
<br />Alternate Facility (or Generator) U.S...EPA ID Number
<br />Facility's Phone: I
<br />Signature of Alternate Facility (or Generator)
<br />-
<br />Month Day ' Year
<br />I __,
<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />1..........d...4 ,at. 1 12. 13. 1 4.
<br />20. Designated Facility Owner or Operftor Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a
<br />Printed/Typed Nan Signature n Month Day Year
<br />•
<br /> ,
<br />', I ,/ 111.0 r)( J•C\7 7 I '°\____ ‘11 Il _7-------, / .-----1
<br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete.
<br />
<br />SIGNATED'
<br />
|