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•— a� ``,., + ..-St g F]'Y.1 C, (J J 4 c 6. 1 >1 J <br /> Please print or type.(Forth designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No,2050-0039 <br /> UNIFORM HA7ARCOUS-11 1.Generator ID Number 1 1. 2.Page l o: 3.Emergency Response Phone r 4-.Manifest Tracking Number <br /> WASTE MANIFEST r, , 7q , 014380358 JJ K <br /> 5.Generators Name and Mailing Address Act MERi YN BEWNDER 'Generators Site Address to comment Nan mailing address) <br /> BNSF RAf MY COMPANY BNSF RAILUYAY COMPANY <br /> 740 E CARNEGIE DR STOCKTON SUBDIVISION MP1119.5 TRACK 139 <br /> SAN BERNANDINO CA 92408 iSTOCKTON CA 95208 <br /> Generators Phone: <br /> 9 P 914 11 <br /> 6.Transporter 1 Comps y sone U.S.EPA ID Number <br /> NRC ENVIRONMENTAL SERVICES INC. C A R 0 0 0 0 3 0 1 1 4 <br /> 7.Transporter 2Company Name.,[ C' U.S.EPA <br /> ID Number /r ;PC( <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Filter Recycling Selivices <br /> 180 W.M"Ave. <br /> dd$OP CA 92318 <br /> Fad s hone. <br /> ga, 9b.U S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Fading Group(f any)) No. Type Duantty WtNol. <br /> lx 1UN3077,ENVIRONMENTAL HAZARDOUS SUBSTANCES.SOLID, <br /> X N.O.S.,(DEBRIS,SODIUM METHYLDITHIOCARBAMATE),9,III QI <br /> LAVA <br /> w 2 <br /> 3. <br /> \, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information - <br /> WEAR PROPER PERSONAL PROTECTIVE EQUIPMENT; JOB/PO# 914 $ <br /> NRC£NVIROMMNTAL SERVICES: 11505 FERRY BOINTi ALAMEDA, CA 94501 r <br /> 951) PROFI1E$ 15090106, 2x55G \ <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION! I hereby dedam that the contents of this consignmew are fully and accurately described a ve y me popper shipping name,and are classified.packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transporta ;o _g to applicable International and national governmental regulators.Ifexport shipment and I am the Primary <br /> Exporter,I cerbly mat the contents of this consignment conform to the terms of the attached EPA)c wmedgment of Consent. <br /> I petty that me waste minimization statement mentted in 40 CFR 262 27(a)if l am a large quantity ger"i or(b)fill am a small quantity generator)is true, <br /> GenerztorslOBerors Pnntedrryped Name Signature*, Ma m Day Year. <br /> �4fv A i'lA_ � � � � !o �s <br /> 16.International Shipments <br /> . F ❑Import to LLS. ❑Epod ham U.S. Part of entry/e'iJt <br /> = Transporter signature(for exports only): Date leaving U.S:' <br /> 17.TransporterArknoModgment of Receipt of Materials _ <br /> Transporter 1 Pnnted/Typed Name signature Monro Day Year <br /> Q Transporter 2 Printed/r of Name Signature r Month Day <br /> [ Year <br /> Ia.Discrepancy - <br /> lea.Discrepancy Indication Space <br /> ❑ Quantity, ❑Type ❑Residue El Partial Reledion Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL Facilltys Phone <br /> QW 18c.Signature of Attempts Facility(a Generator) Monro Day Year <br /> Z <br /> w19.Hazardous Waste Report Management Method Codes pe.,codes for haLudc us waste treatment disposal,and recyding systems) <br /> O 1 2 .. 3. 4. <br /> 20.Designated Facdity Owner'or Operator Certification of receipt of harardeus rnatedals covered by the man pt as note m tem Igo <br /> PnnteNryped Name Sig c Mis nth Day Year <br /> t <br /> 114 114 A <br /> EPA Form 870422(Rev.3-05) reviouseditonsareobsolete. DESIGNATED FACILITY TO GENERATOR STATE(IF REQUIRED) <br /> 12168.0394 <br />