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Please print or type. Form Approved.OMB No.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' g C 2 0 3 0 2 0 7 .1 `888-377-726 t JJK 5.GueratorspamP and tails Add ess. 3N est .ecelvin.g G nesjtors�i.le.1 re t.differeat th Jnm3iPpB address) Union i actTic allt�oai3 oto i3HD �Jnlon acI?c t rr,eo, 6520 Corporate Dr. K-2 E 8th Street indianapoiis IN 46278 Stockton CA 95206 Generators Phone: y 1 6 7 0 5 - 5 2 4 6.Transporter 1 Company Name U.S.EPA ID Number Hrner"iGan integrated Services, Inc. f_ ii 17 4 f; 'i Pt 7.Trapater 2 Company Name U.S.EPA ID Number 3�3 8,Designated F41ity Name and Site Address U.S.EPA ID Number Crosby Y(2verton,Inc. 1630141. 1 71:1't Street Long 9 e a c h Faciity'sPhone: 50i' 432-5445 i_ 1�., Dn t] ye a 0 l 0 1 q ga 9b.U.S.DOT Descri tion(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Grasp(if any)) No. Type Quantity Wt.Nol. 1.RQ,NA3077,Hazardous 1, ante,solid,n.o._.(Chrorrerum),a,PGIII D007 223 o X (DrO?) w 2. Sent to DTSC 2.16.22 - RG 3. 4. 14.S��pw�ecial Handling Instructions and Add:hsonat Information Itli#zLy!5 [rear Appropriate PPE tahen handling *.,Tete- Weightz or =nlumc zre approximate 9b-1) Profile Nuxaber: 120828 ER#171 AIS Job Number:81046-50 (1 D-1) v. 81046-52 (2 Elms) WR#6113 i 6 1 2 ru 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipp g name,and are classified,packaged, marked and labeled/placarded,and are fi all respects n proper condition for transport according to applicabi-international and national governmental regulations.If expart shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attachad EPAA/,knowledgmnt of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)cc(b)(if I am a small quantity generator)is true. C-enerator'00,ffercr's Printed/Typed Name Signature Month Day Year Melvnda Borrego on behalf of UPRR ©t JZ ( 12 16.International Shipments F ❑Impat to U.S. ❑Export frau U.S. Port of e ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment e(Receipt of Materials Transporter 1 Printedfryped Name Signatur Month Day Year e-teSi L , 'h, ©I 21 Z Transports 2 P tedfryped Name Signature Month Day Year Za 18.Discrepancy 18a.Dscreparn y Indication Space ❑ Quantityyp j ❑Type ❑Residue Partial Rejection El Full R6ection Marrfest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facity's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) � 1. 1 1 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted n Item 18a PrhtedlType Name Signature ' Month Da' Year �l t EPA Form 8700-22(Rev.12-17) Previous editions are obsdete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM