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GENERATOR NON-HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />0 LO 0 Oddd F, 3 1 <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />800-624-9136 <br />4. Waste Tracking Number <br />NH 1 1 - 2 1 - 0 0 4 5 0 <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Brl SF RAILWAY B rq SF RAILWAY COMPANY <br />740E CARNEGIE 6540 S AUSTIN ROAD <br />SAN BERNARDINO CA 92408 1 STOCKTON CA 95215 <br />Generator's Phone: 20Q am- 6.12 8 1 I <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Patriot Environmental Services ICADO 53866794 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Potrero Hills Landfill <br />2875 Potrero Hills Lane <br />Suisun City CA 94585 <br />Facili 's Phone: 70 7 49g. gaile I r` ,iN P 0 0 0 0 8 9 4 6 8 <br />10. Containers it. Total 12. Unit 9. Waste Shipping Name and Description <br />No Type Quantity WI.Nol. <br />'Non-Hazardous Waste, Solid (Soil Contarri.nated w/ Trace Diesel) <br />45 <br />2. <br />00 1 CM — <br />3. <br />Special Handling Instructions and Additional Informafion 1) ERG#135 PH titles4e, , Bi4‘ /5,ki-a 14,,,, <br />Aoia.,/3 PC 1, JC/D*1 1 1-21-00450 vrar aoproprint,-P nhe,r1113nclling iaste . <br />GENERATOR'S/OFFEROR'S CERTIFICATION: thereby declare that the contents of this consignment are funy and accurateiy descnoed above by the proper snipping name, rid 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 />Generator Printed/Typed Name Signature -9 Month Day Year y/Offepr's <br />an &Ali el "AO"' i 671., I la?1 9 1.2/ <br />—I <br />— <br />International Shipments El Import to U.S. Export from U.S. Port of entry/exit. <br />Transporter Signature (for exports only): Date leaving U.S.: TRANSPORTER Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name(_.() r' / ; , . / . . ,jSignature Month Day Year <br />I 102 I 9 la( <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />I I I DESIGNATED FACILITY 17 Discrepancy <br />Discrepancy Indication Space El Quantity Type Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: <br />Signature of Alternate Facility (or Generator) Month Day YeN <br />fest except as noted in Item 1 a 18. Designated Facility Owner or Operator: Certificat rece. . mated. c ered by the mani <br />fr <br />Printed/Typed Name Signature <br />i <br />firifig <br />Month Day Year <br />id OCi •D4 I <br />DESIGNATED FACILITY TO GENERATOR 169-BLC-0 5 11977 (Rev. 9/09)