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-** GENERATOR NON-HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />- REQU I RED <br />2. Page 1 of 3. Emergency Response Phone <br />S88-8 -: 2 i1.7, <br />4. Waste Tracking Number <br />Generator's Name and Mailing Address Att. Manest R?.ceiving Generator's Site Address (if afferent than mailing address) if Union Pacific Railroad oJo GHD Unicn Pacific Railroad <br />6520 Corporate Dr. 37.9488198, -121.27E14699 <br />Indianapolis IN 46278 Stockton CA 96203 <br />Generator's Phone: g + 6 71C1- ggQ9 <br />Transporter 1 Company Name U S. EPA ID Number <br />Patriot Environmental Services f—AD053 - 6C 7 9:1 <br />7 Transporter 2 Company Name U.S.EPA ID Number <br />Faciiity's <br />8 Designated <br />Potrero <br />3075 <br />Suisun <br />Facility Name and Site Address U S EPA ID Number <br />Hills Landfill <br />Potrero Hills Lane <br />City CA 94585 <br />Phone: in 7 42-4 . gfi Fin I'CARO 0_0 0 8 9 4 6 6 <br />9. Waste Shipping Name and Description 10. Containers 11. Total ... 12. Link <br />No. Type Quantity WINol. <br />Non-Hazardous Waste, Said (Paint and adhesive buckets) <br />0 0 I CM <br />. .., <br />-4 <br />' <br />13. Special Handling Instructions and Additional Information , <br />Cob# 11-22 -00543 <br />WR: 011556 RMCC #:: . 2022 -08-02-71''LEK i <br />Profile (z) : PM-22-7401— <br />- r-- D_ t _ <br />14 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully 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 applicable International and national governmental regulations. <br />Generator's/Offerors Printed/Typed Name <br />OA 1,,,11,( 4 briut • faticiAzoLbe- <br />Signals Month <br />to <br />Day <br />24- <br />Year <br />2 <br />,...1 International Shipments Import to U.S. Export from U.S. Port of entrylexib <br />Transporter Signature (for exports only): ' Date leaving U.S.: TRANSPORTER Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printe ad Nat e Signature Month Day Year <br /> <br />A-(01‘,/ A--1.firp-CZ i I ICS I 1 2 ? <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />I I I I -4E-- DESIGNATED FACILITY Discrepancy <br />17a. Discrepancy Indication Space <br />Quantity Type Residue Partial Rejection Full Refection <br />Manifest Relerence Number: <br />llb. Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: <br />17c. Signature of Alternate Facility (or Generator) Month Day Year <br />18 Designated Facility Owner or Operator. Certification of receipt of materials covered by the manifest except as noted in [tern 17a <br />Printed/Typed Name Signature Month Day Year <br />1\ rL-- I NE---- 110 1 7 n I-7 1 <br />169-BLC-0 5 11977 (Rev. 9/09) DESIGNATED FACILITY TO GENERATOR