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Please print or type.(Form designed for usenn eii(a(12-pitch)typewriter.) ` Form Approved:OMB No.2050 0039 <br /> I.Generator ID Number 2.Page 1 pf 3.Emergency Response Phone anifeat Trackln um r <br /> i UNIFORM HAZARDOUS 1. 41FrB8•B772 D106751 FL <br /> WASTE MANIFEST CALOD0365717 <br /> 5.Generet, Nama'and Mail.Add ess erelot s StieAddress Qf d eront than mairr�9 s) <br /> UNtVERSAL SVC REf3YCLWr. Ain William Mendonclil <br /> 3200 S.E(Dorado St. <br /> Stockton,ICA 9s2D6 <br /> Gan <br /> erator s Pt e:' 209.944-M5 <br /> U.S,EPA ID Nu mbar <br /> 8, ranspater 1parry sine <br /> Union P;agtfio Lines CO Dani 792 i <br /> U.S.EPA ID Number <br /> 7.Trarsporter2 Company Name <br /> 8.Das ated FedEty eine and Site Address U.S.EPA ID Number <br /> ECDC En*onmentW UTC08301220i <br /> I 111 West Hi(}hhVe5f 123 <br /> X651 East Carbon:UT 84320 USA <br /> FUR a Phone. <br /> go.U.S,DOT Description(fndu*g Proper ShlppIng Name,Hazard Class,ID Number, 10:Contalnem 11,Total 12:Unit .13.Waste Codes <br /> HM ark Paddaig Group(d any)) No. Type QuantityWI Nd. <br /> y 6,1 <br /> F x ('JQt'4-r'�<,r�re`¢�r�t',ARDOUS WASTE,SOLID(fdt00,DQT ie9tiiated) <br /> ai <br /> t z. 2. L}tSLr$ <br /> W 3 <br /> 4: <br /> 14.Spadal Handling Instn ctlo(4andAdditional Inform8tiot ': 77 <br /> UNIERSAL SERVICE RECYCI NGI PROJECT RAILCAR NO, <br /> NoMRCRA Shreddt r Resi¢ae "�( /:31•$"r_ <br /> ECDC Prof W4041,18 8405' <br /> 15: GBNERATOR'S1oPFEROR'S CERTffiCATiON:1hereby declare that the catlepts of this consignment are fully and accurately described above by the proper shipping name,and are dassifiei,packaged., <br /> marked and lab"placaped,end are in all respects in proper condition for transport a=rdlmj to appl4cab(e lntematbnal and eat onal governmental regulations:IF expert st 7xnent and i am the Primary <br /> t certify that the carrienis of itrfs-consignment confdimlo the terms of the attached EPAAdcnovrfedgrneof of Consent <br /> I cor*that the wasta minindullon statement idoirtifled In 40 CFR 26227(s)of I am a large quantity generator)or(b)(4 i am a small quantity gonaetor)is true. ay. eer <br /> y j <br /> r— <br /> 18•international SNpmanb import to U,S, Export from U,S& Port of entrylexg: <br /> Trees tura for MrIs <br /> U.S.: <br /> 17.Trannportcrl w+ledgiIof.Rec*ofMaterials y oar. <br /> � Tiarsporter t yped N na uro <br /> Trensportar2PrniedfrypedNama nature ant ay ear <br /> i@.D�crePai?cy rr----t, <br /> lea.Discrepancy indication Space ElouanUly L 1Typa ❑Residue El Partial RaJactarart 0 F' Reysdllod <br /> Manifest rteference Number. <br /> U.S,EPA ID Number <br /> 18b:Alternate Facility(Of 139MM100 <br /> W Fad s Phoner <br /> i&.SgnahuaofAltamate adGit(orGanerala) Month Day YearLU <br /> '. <br /> Q <br /> —19H..W.,Wast,Report Management Method Codes Q•a.,codes for haiwdmis waste treatment,disposal,and recycling systems) <br /> Ck <br /> M 3. <br /> UJIM4. <br /> tl 2. <br /> 20,Designated Facility Omer of Operate Cattific ation of receipt of hazardous materials covered by the manifest except as polad in Item Ise 1 tfi ay Y <br /> t ypetl ema igneture �'°Q , . <br /> EPA Form 8700-22(Rev.3.45) Previous editlorts are obsolete. DESiGNATE6NILITY TO GENERATOR STATE(IF REQUIRE()) <br />