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NON-HAZARDOUS 1.Generator ID Number 2.Page`1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST _. 'A D 9t _ ._ 0 ^ 1 i s t 1 X98-8� t . 287 1 � 121 1: {_ to t <br /> 5.Generators Name and Mailing Address Att: h1 anif mL; -oc-r.,jn aGenerator's Site Address(if different than mailing address) <br /> Union!`�i dh w� F.Ar_-d coli(31-lD hind+n f adliff R�2ilr(o di- i-jr—R ;` <br /> ,54 Sm:%jrporat.'Dr. L_:: E SL)i S'trei i <br /> lndianl.a( fit_" IN 40-32272 cJ l_C+it + U <br /> Generator's Phone: 910 Ell0-5 12 W1 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> i ca c. i Servioes, Inc. C A R [ C1, 0 .1 ( ,: <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Despaled Facility Name and Site Address U.S.EPA ID Number <br /> 1110 CA R G:.j`ePppki' <br /> AN FRANCISCO C.-A 94124 <br /> Facility's Phone: 480 233-0404 IN rr, t t' N It r 0 <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WtJVoi. <br /> 1 NIon-Cull Regulated s01aterial,`o id(Railroad Ties) <br /> 0 30 <br /> wVit' Q '1 4�to V <br /> Receiveri <br /> z 2. <br /> w <br /> (7 <br /> FEB 14 2022 <br /> 3. <br /> GHD <br /> Indianapolis <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> A l wziy+ `ire'.."r Aper ril- -re PPE -when hriiid iiag 'w P--a;tom Weight5 5 o -L of rae it <br /> 1- p'ro i le## A18 Job Nurltbe :80061.--6 tj-R#;f' 400 Bi a� <br /> L/ht11-u"34g6lf <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this cq riment are Ily 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 aoco in to appli em on and ationai governmental regulations. <br /> Generator's/Offeror's Printed/Typed Nameign ure' Month Day Year <br /> J 15.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> cc Lu <br /> 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> y 7 t 2-- <br /> z Transporter 2 Printed/Typed Name Signa Month Day: Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space El ❑Full Re ecilon <br /> ❑Quantity ❑Type ❑Partial Rejection ) <br /> Manifest Reference Number <br /> ? 17b,Alternate Facility(or Generator) U.S,EPA ID Number <br /> V <br /> tai Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> C7 <br /> Lu <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> [Printed(iypecl Name Signature Monthay Year <br /> Cb <br /> 169-BLC-0 5 11977(Rev.9/09) DEUIGNATED FACILITY TO NERATR <br /> 1 <br />