COMPLIANCE INFO_2022 - Laserfiche WebLink

Home Browse Search

Please print or type. Form Approved.OMB W.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C A G 9 8 2 O 3 0 2 O , 1 , 18,98 877-72157 1021324581 JJ K 5.Generator's Name ar)d Mailing Address Att: Manifest Receiving Gemrater's Site Address(if different than mailing address) Union Pacific Railroad cl0 GHD Union Pacific Railroad 6520 Corporate Cir. 833 E oft Street Indianapolis IN 46278 Stockton CA 95206 Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number American Integrated SeRices, Inc. I.C. A R 0 0 0 1 4 8 3 3 8 7.Transporter 2 Company Name U.S.RA ID Number 8.Designated Facfity Name and Site Address U.S.EPA ID Mimber Crosby sic Overton,Inc. 1 1830 VV. i 7th Street Low Beach CA 90£13 _ Fa6lity's hone: o F f Q .f d it P n 1 'P 9a 9b.U.S.COT Description(includiry Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity. Wt.Nol. ce 1Non-RCRA.Hazardous Waste,Liquid(Used Oil) r 331 221 CAVI �1 C, z 2. w t9 3. / 4. 14.Special Handling Instructions and Addilional Information A1v7ayz Wear Appropriate PPE when handling waste- Weightm or volume are approximate- 9b.1) Profile N+-umber: 113299 AIS job Number:79023-136 71JR423616 192 "65- 15. GEN ERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignmenk are fully and accurately described above by the proper shipping name,and are classtfu:d,packaged, marked and labeled/placarded,and are in dl respects in proper condition for transport according to applicable Wemafro d and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents ct this consignment conform to the terms of the attached EPA Acknowledgment of Ccr:sew... I certify that the waste minirryzalion statement identified in 40 CFR 262.27(1)(if I am a large quantity generator)or(b)(if I am a small quantity generator)Is true, Signature Month Day Year Generator's/Offeror's Printed/Typed Nare 6 �!if' a'�rIJI, �►teb RTTAA !A✓ kfiftr dr-UP4tx- ,l 16.International Shipments F- ❑Import to U.S, Export from U.S. Port of entry/exit: ? Transporter signature(far exports only): Date leWng U.S.: rY 17.Transporter Acknowledgment of Receipt of Materials aTransporter 1 Pr•nted/Typed Name Signature Month {Day Year o A Transp r 2 Printed/Typed Name Signature Mcnth Day Year ] j <,))a s 3 18.Dscrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Res;due ❑Partia Rejection El Full Rejection Manifest Reference Number: 18b,Alternate Faciity(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature of Alternate Facility(cc Gererator) Month Day Year a z CD 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,&-posai,and recycling systems) 0 1. ii 2. 3. 4. i 20.DesSgnated Facili y Owner or Operator:Certification of receipt of hazardous materials covered bey the manifest except as noted in Item 18a PrintedtTyped?Jame - Signature Month DD Year ,�T J � -, l V\-14 1 4 C-- J---\ I I I aEPA Form 8700-22(Re >12-17) PrevWs editions are obsolete. ESIG TED FACILIV TO EPA's a-MA IFEST SYSTEM