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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 t- `�' � t t t <br /> 5.Ge `ator's N,atne d t jigg Addre s >; ' anilfe 1 ecell,in G calors SStte Ad�fires if ddifferen th address <br /> 3rl tftrt t-�01 lCc i�, (trC�d 4.:#i;�i; i�C",+ rii0n F,12 Itit;, IIrOc��- � ) <br /> 6-520 r=parr r r g ,C}t. 83? h'S'treet <br /> Indianap-01iv IN 40278 -tc]ickt0n '_A <br /> Generator's Phone a 15 7P1a_•-512-S <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> American Integrated:Se tiC®c, In . C A R t.3 0 0 '1 1 3 3 d <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.DesW(p�ated FFaacili"ame.and Site Address U.S.EPA ID Number <br /> t�.epiullie-Service-, <br /> IAN FRANCISCO CA 04124 <br /> Facility's Phone: N r $ R 0 u i r e d <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No, Type Quantity Wt.Nol. <br /> cc 1. flan-DOT Regulav d fiat=t-lRl,Solid(I,'ailroad Ties) <br /> 0 <br /> 0 0A Cls; ,'t, I <br /> z 2. <br /> Lu <br /> J Received <br /> 3. <br /> FEB 14 2022 <br /> 4. 01 <br /> D <br /> indlanap®1is <br /> 13.Special Handling Instructions and Additional Information <br /> Al-way!: Wazr Appropriate PPE --then handling Weight- _L- volurnee re ar.p_o itazte:_ <br /> i. Pr0ii1e- 444a" 5 AIS Oob Numb ea. 00061-6 V1t#440r0 Figs# <br /> �=-M <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this cwnsignme t are fu 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 app e l tlpqeqancl national governmental regulations,' <br /> Generator's/Offeror's Printed/Typed Name Signatu Month Day ear <br /> Mel~rrd;DiDrrego On behalf 0r UP :F <br /> I wtuu/�-- I* —'(!f> <br /> J 15,International Shipments <br /> ❑Import to U.S. Export from U.S, Port of entry/exit: <br /> Transporter Signature for exports only): Date leavin U,S,: <br /> cc 16,Transporter Acknowledgment of Receipt of Materials <br /> ® Traorter 1 Printed yp d a t Sig ure Mont bay.- ear <br /> z Transporter 2 Printedfryped Na , ;Sig <br /> at, <br /> Month Day r <br /> o aC -Cz� LCL zz <br /> 17,Discrepancy <br /> 17a,Discrepancy Indication Space ❑Quantity ❑Type 1:1Resi e El Partial Rejection EJ Full Rejection <br /> ' <br /> Manifest Ref ence Number: <br /> 17b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> _J <br /> U <br /> LL Facility's Phone: <br /> Lu 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> N <br /> W <br /> O <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a - <br /> Printed/Typed Name � Signature I <br /> nth Da'ILy Year <br /> UIA��r� I <br /> 169-BLC-0 5 11977(Rev.9/09) DESYGNATED FACILITY TO GENERATOR <br />