DERR-2024-005464

-RTS Emergency Response and Training Solutions
Appendix 4
Waste Disposal Documents
ERTS
11231 Phillips Industrial Blvd. Bldg. 1, Ste 300 • Jacksonville, FL 32256 • USA
phone number: 440.349.2700 I fax number: 440.349.6713
ertsonline.com
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NON~HAZARDOUS WASTE MANIFEST •
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PleaH pm1 o, type (Fom, dNigr19cl !or use on 9lile (12 pilch) typewm,,r) ~
· lit NON-HAZARDOUS 1.G_,,,..USEPAIDNo. Menilelt • • 2.Page1
WASTE MANIFEST, CESQG Docu!MntNo.NH89826-02 o1 1 "t--..;..;..;"-'-=..;...:=::...:.;.;,;..;.;..;;.:.:..=.;::;;.:..__;-:-''--------......:;:;..:;:_=-:::._ ______ +-__ .....,;=::.==;...:.:=--....1----~
lit 3. Geowator'• ~and~ Addrffa H. ta Add.au
Fed Ea , UII( · r··
760 N Frankin PKWY
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D. o.ignalld Fac:lily Name and Sile Adclnl•
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Clean Harburs Grassy Mou~in LLC
3 Min East 7 Mies Nonll of Knolls
~ Grantsv•. UT 84029
6. US EPA ID Number
S. Trant!)Of1ef 1 Phone
8 .. US EPA ID Number
O.Tn111-'.,2Phone
10. US EPA 10 Number E. Slate Faclli!Y's /D ...
UTD991301748· . ~ F. F~a ~
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11 . WASTE DESCRIPTION
.-No. Type _ft,., WIN'1o . '1 .
•. ~~S.NONO.O.T.REGULATED.(DIESEL,WATER. l -rr ~.; ~OeJo ·G ·f
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EMERGENC'Y ~E II: [phone] ~··
· GENERATOR: Fed &
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· 1e. GEl'ERATOR 'S CER11FICATIOH: I hereby certify that.,. eonient• of !hi$ llipment .,., lull\l and 80CU111tely cl91CIIMld and are In Ill respect,i _.
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.. ":-,_ In proper cOfldltion IOI t,antport. The matenals descfibed on this ma~• are not tul>ject IO federal hararoous wute regutalona . .J ,
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Mot,/11 Day Year
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"-NON-HAZARDOUS 1· o..,e,_., USEPAIO No. =.rNauH~e-Mt-, '2-1 ... ,,.. t
OI WASTE MANIFEST CESQG n -~ , ..... _...;.;..;...;.;;;;.;;..;;;...;=.;.;..;:.:.,;.,.=;_;,_---i __________________ -+,,,,.,..,.....:...,,..,,.,,.....------'------1
... 3-f:i'GNameMdMaling-,_ = ~-••: :-
<Ill. 150 N Frankin PllWY . ..,,..,. ,., , ~
North Sl.C UT 840M • lllt 4. e.ntra!OI"$ Ph0ne tf904l 29M093 ,
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5. Tranapof!er 1 Company Name •• .._ __ , _ __
...• ca.an Hartws EM ■•--dalSerwicN. IIIC.
7 . TfWIIP)fler 2 Company Name
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6 US EPA 10 Number
MA0039322260 B. Tranapo,11, 1 Pl10ne ... ..,
8 . US EPA 10 Nun-ber
D. TrllnlpOIW 2 Phone
10. US EPA 10 Nunt)er
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GENERATOR: Fad & ~
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16. GEHERATOR'S CERTIFICATION: I =-cerlify that Ille c:cn-af 111ia lhipmer,t.,. lullv and _,.rely_ Md are in al ,apcta
in -a:indililln lor ~-The ONcribed en !Ilia manile9t 11ft rot Slllljlct ID,-_.~ -,-gulationl.
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NON-HAZARDOUS WASTE MANIFEST
Pleue pmt"' type (Form delligntd tor use on elte (12 pllell) typewl1le,) UT 230028182C-OOJ.
NON-HAZARDOUS I.G-.IOr'sUSEPAIONo. ManllNt
WASTE MANIFEST CESQG Ooc:1.men1No.NH8&826-0t
3. Generalar's Name andM-.g~
Fad&
7IONF ...... PllWY
... Sl.CUTMOM
4. ~ Phone ( '8041}29&-I093
5. T!'llllplt1et' 1 Company Name
Cla• Harbors EtwinnnelllalSamaas, Inc.
7 . Tranapo,1er 2 Company Name
9. O..gnaled Faclllly Name and Site Addr-
a.. fflfllars Grassy MGUlllain LlC
3 IIIIN East 7 Min flonlt of lllltlls
GriiitlRlllt, UT 84029
11 . WASTE DESCRIPTION
II.
8 .
10.
US EPA ID Null"blr A. SWe TrantplX!er'• ID
MAD0393222BO B. TllnlpOl1ilr 1 Phon9
US EPA ID Number C. Sia Trll1tp0tteft ID
D. Tflllll)Olts 2 Phone
US EPA ID Number E. S18le Fac:Nlly'& D
UTD991301748
F. F~• Pllone
[phone]
Containers 13.
Ne . Type
Total
Quanllly
a. NON HAZMDOUS,NON D.O.T. REGUlAlED, (DIESEL, WATER.
:I.Page 1
Of i
14.
Unit
Wt.NcA .
ANONVl) I r-r ltJOo G
G b.
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G. Adlllonal Oescrlp!kn for Malerials l..ill9d All0¥e
11a.Clt26420fit.B
H. Handling Cocla8 lor Wa&les Ualed Aboff
15. Special Hendllng 111111\dona and Additional lnlo,,,..flen
GENERA10R: Fetl&
d88Cl1bad on !hie~""' not lo -eoJ.d s ;-~-o-?o'o-'i {)() I
18. Tl8nlpOl1er 2 Adcnowlldgement al Recelpl Of Malenals
Prlrillld/Tw,ed Name
F 10. o.ompency lndc:ation Space
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DlilAI
Monlh Day
2-l.
Dato
Month Day
Due
/llonlh Day
Year
2..3
y_.
Year
1t--------------------------------------------t 20. FIICillly Owner or Open,w, CerllcatiOn DI receipl DI the waa!e matJoriaas 00ttollld by 11111 ......nwt. except • naiad ~ Item 19.
~1---------'=-.------__.+.._...,.....,.,.:~~"'---c-. --1 f Printed/Typed Name Month Illy Year
y 2 ~
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Genera1 :>r's Phone .
6. Transporter 1 Company Name
7. Transporter 2 Company Name
8. Designated Facility Name and Sile Address
9 Waste Shipping Name and Descr1)1lon
1.
2. Page 1 of 3. Emergency Response Phone
Generator's S~e Add ress (if different than mai ling address)
'
10. Containers
No . Type
U.S EPA ID Numbe1
U.S. EPA ID Number
U.S. EPA ID Number
11. Total
Quantity
12. Un~
WtNd .
W1----i------------------------------+------1r----t------t-----+---------z w
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2.
3.
13. Speci.1I H~ing lnslructlo11s and Additional Information
14 . GENERATOR 'S CERTIFICATION : I cenify the materials described above on this manttesl are not subject to federal regulations for reporting proper disposal cl Hazardous Waste .
Generator'sJOfferor's PrintedlTyped Name SignallJre Month Day Year
0 Export from U.S. Port of entry/ex i.._· _________________ _
a: 16. Transporter Acknowledgment of Receipt of Materia ls ~ Transporte r 1 Printed Typed Name
0 a.
Dale leav· U.S.:
Sigflature Month Day Year
<1)1-,------,---.,-------------------'-:c-------------------~...,..,..-.~c:,-~..,..,--~ TransportBr 2 Printed/Typed Name Signature Mon1 Day Year
a: ....
17a. Discreparx:y lndir:alloo Space
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17. Discrepancy
~ 17b. AHemate Facility (or Generator}
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Oouanti!y □Type D Residue □ Parlial Rejection D Fu t Re1ec1Ion
Manifest Reference Numbe r:
U.S. EPA ID Number
~ Facill 's Phone . ~ 1--,1""'c."'"Slg'-'-na-tu""'re-"ol-A11-ema_e_F_acility __ (_or_G.,..ene-ra-tor)--------------------------~---------Mon-lh--Da_y_""'Y.,..e-ar-
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18. Desigflated Facility Owner or Operator Certification of receip1 of materials covered by the manHest except as noted in I1em 17a
Printed/Typed Name Signature
TRANSPORTER #1
Month Da y Year
/ SITE
I
~frREGToma;--mrFmur-=-924-854 0 \ 'srrEOl i ncKET , 1070'855 i cELL 1
8833 N Rowley Rd-North Skull Valley, UT
CUSTOMER GrdyMar Environme nta l
A-1 n: Accounts Payable
".'ooele , UT 8 4 07
~~r· tact :4186232705
Generator : FedE~: Ground
, \ l£l
84029
WEIGHMASTER
DATE/TIME IN am DATE/T
VEHICLE :) CONTAINER
REFERENCE
BILL OF LADING
TARE WEIGHT 4 2 ,960 NET WEI GHT 4 ,260 INVOICE
EN VI RONMENTA L FEE
FUEL RE COV ER Y FEE
DESCRIPTION
UID Oc 1q1n:UTAH 10 0\
Signature ____________________ _
RATE EXTENSION TAX
'--Than~youfor ~ou Lbusine.55._ ________________________ --'--------'------~~---
The undersigned 1nd lv1d ua1 s1g n1ng thll docume nt on behalf of Customer acknowl edge• th al he o r ahe hu read and understands the 1erms end condlllons
on the revorse side and ttia l he or she hH the authority to sign !his docu ment on b<>ha lf of the c ustomer.
RS-F042U PR (04 119) SIGNATURE ____________________ _ '-
am
TOTAL
NET AMOUNT
TENDERED
CHANGE
CHECK I
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a:
0 ~ a:
5. Gene ra1or's Name and Mailing Address
Generat~r's Phone:
6. Transporter 1 Company Name
7. Transporter 2 Company Name
8. Designa1ed Faci ify Name and Stte Address
9. Waste Shippng Name and Description
1.
2. Page 1 of 3. Eme rgency Response Phone
Genera1or's Stte Add ress (ff differen11han mailing address)
10. Containers
No . Type
U.S. EPA ID Number
U.S. EPA ID Number
U.S. EPA ID Number
11 . To1al
Quan1ily
12. Uni
W1Nol .
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2.
3
4.
13. Special Handling Instructions and Adcfrtional Information
14. GENERATOR'S CERTIFICATION : I certify the materials described above on this manifest are not subject to federal regufa1ions for reporting proper disposal a Hazardous Waste.
Generator's/Offeror's Printed/Typed Name Signature Month Day Year
..1 15. lnterrational Shipments
~-0 Import to U.S 0 Export lrom U.S. Po rt ol entrylextt _· _________________ _
Trans rter Si nature (for ex rts on ):
ffi 16. Transporter Acknowledgment of Receipt of Materials
le Transporter 1 Printed/1 yped Name
0 n.
Date leavi U.S.:
Signature Mon th Day Year
Ill >---------------------------~--------------------~--~-~--~ Transporter 2 Printed/Typed Name
I!: t 17. Discrepancy I ,1,. ,_,.,, ,,...,.,, """
~ 17b. Alternate Faci lify (or Generator)
:::; u
Oouantirv □Type
Signature Month Day Year
OResidue 0 Partial Rejection 0 Full ReJection
Mani fest Reference Number.
U.S. EPA ID Number
~ Fa ci li s Phone : @ 1-,-1-c.""'sccigna-tu-'-re"'"o-t Alt-ema-te_F_ac_u_ify_(_or_G-en-e-ra-to-r)-------------------------~----------Mon-th--D-a-y --Y-ear-
~ ~----------------------------'---------------------'---~-~--
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18 . Designated Facility Owner or Operator. Certifica tion of receipt of materials covered by the manffes1 except as noted in Item 17a
Printed/Typed Name Signa1ure
TRANSPORTER #1
Month Day Year
( SIT E WASATCH ru,;c;rON~I~DE ILL ao r=g:z-4·-=13'51 REPRINT
8833 N Rowley Rd-North Skull Valley , UT 84029
'>--c--=---'..,..~:U..---------------------------<;
CUSTOMER ,. __ yMa r Enviro nm en ta l
n : Ac c ou n t s Pay abl e
Tooe l e , UT 8 4 074
Co nt r a c c :4 18 62 3 2 31
Ge nerato r :FedEx G r o u n
SITE TICKET I CELL
WEIGHMASTER
DATE/TIME IN
VEHICLE CON TAIN ER
REFERENCE
BILL OF LADIN G
··~--Lta-~\-----------------~H~l ~BO~U~~l-~-----"', , ':-ff½tt'l'----;::,-,.;rr----.,NE'f-'l'ON 3 a z:" > SCALC IN GR03'9-W-CIG!l 'l' z:1 1 z:11
SC ALE OU T TAR E WEI GHT I NVOI CE
QTY
9 . n
I EN VIRONM ENT AL FEE l
F UEL RECOVERY F EE
DESCRIPTI ON
O rig i n:UT AH 100 %
Signature ______________________ _
RATE EXTENSION TAX
'-I lld lll\ .. y.auJorh,DIJUlllSio es,-----------------------------~----~-----------
Th e unde,sIgned h>div l!lual signing !his documenl on behalf o f Cuslomer acknowledges that he or ahe has read and und erslends t he terms and conditions
on the reverse aide and thal he or she h as the au1h or1t y 10 sign this document on behalf of lhe customer
RS-F042UPR (04 /19 ) S IGNATUR E ____________________ _ '-
TOTAL
I miiiM@ (
TE NDER ED
CH ANGE I
CHECK, I
a:
0 < a:
NON-HAZARDOUS
WASTE MANIFEST
.... • I
. . • • • : •· •• t .•••
Generato(s Phone :
6. Transporter i Company Name
7. Transporter 2 Company Name
8. Designated Facility Name and Site Address
Facili 's Phone :
9. Waste Shipping Name and DeSCllption
1,
2. Page 1 of 3. Emerge ncy Response Phone
Generato(s Site Add.ress (if different than mailing address)
10. Containers
No. Type
U.S. EPA ID Number
U.S. EPA ID Number
U.S. EPA ID Number
11. Tola!
Quantity
12. unn
WIN~.
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w
0
3.
4.
13. Special Handling Instructions and Additiooal Information
14. GENERATOR 'S CERTIACATION : I certify the materials described above on this man ifes are not subject to federal regulations for reporting proper disposal ct Hazardous Waste .
Generatofs/Otferofs Printed/Typed Name Signature Month Day Yeat
D Export from U.S. Pon ot entry/exi-· _________________ _
a: 16. Transporte r Acknowledgment of Receipt of Ma terials ~ Transporter 1 Printed/Typed Name
0
Q.
Signature
Date leavi IJ .S.:
Month Day Yea r
"'r::----::--:,-:--:::--:-:-:--------------------'--:',-------------------........ --..__ ........ -,-_ ~ Transporter 2 Printed/Typed Name Signature Month Day Year
I=
17a. Disctepancy Indica tion Space
1
17. Disc repancy
5 17b. Alle mate Facility (or Gene rator)
u
Oauantity □Type D Residue D Partial Rejection D Full ReIection
Man ifest Reference Numbe r:
U.S. EPA ID Number
i:f Facili ·s Phone : @ f-,--'-1"-c.""'sc.cigna--'-tu"-re.c.o""f A-lt-ema-te_F_a_cil_ity_(_or_G_e_ne-ra-to-r) _________________________ __., __________ M_on_th--D-a-y--Y-e-ar-
< ~-----------------------------....._ ___________________ ........ __ ..__......._ __
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18. Designated Faci lity Owne r or Opera tor: Certification of receipt of materials covered by the man~est except as noted 111 liem 17a
Printed/Typed Name Signature
TRANSPORTER #1
~;onth Day Yea r
SITE ITCFrREGT~r'Ill.---Sur=-9
8833 N Rowley Rd -North Skull Valley, UT 84029
1
cus.,..OMER GrayMar Env1ronmenta l
OTY
Att n : Acco unts Payab le
'T 84 07 4
Con-r a c t:4 18 6232 31 1
r.e n e rat o r :fedEx Gr o und
TARE WEIG HT
ENVIP ONMENTAL FE E l
FUEL RE CO VERY FEE
41 ,400 NET WEIGHT
DESCRIPTION
Oriq1n:UTAH 10 01
SITE TICK ET •
WEIGHMASTER
DATE/TIME IN
VEHICLE
REFERENCE
BILL OF LADI NG
.19
2 0 ,380
Signature _____________________ _
CELL
Ashley H.
a m
CONTAINER
IN VO I CE
RATE EXTENSION TAX
, 1 aaa11 you for k ou r busine""-____________________________ __. _____ .__ ______ .._ __ _
The undersigned lndiv1du111 slgntng this document on behalf of Cuatomer acknowtedgos that he or she haa read and understands the terms and condlUona
on tne reverse aide and lhal he or she hes the authority 10 sign this document on behalf of lhe cu91omer.
RS -F042UPR (04 119 ) SIGNATU~E ---------------------
:57 am
TOTAL
NET AMOUNT
TE NDERED
CHANGE
CHECKI
IC
0 ~
IC
General:>r's Phone :
6. Transporter 1 Company Name
7. Tran sporter 2 Company Name
8. De~gnated F acilily Name and Site Address
9. Waste Shipping Name and Description
1.
2. Page 1 of 3. Emergency Response Phone
Generato(s Site Address if different than mailing address)
TH Tl
10. Containers
No . Type
U.S. EPA ID Number
U.S . EPA ID Number
U.S. EPA ID Number
11. Total
0uan hty
12. Untt
WtNol .
w---1------------------------------+------1----+-----+---+---------z w
C,
2.
3.
4.
13. Special Handling lnstruc\ions and Additional Information
14. GENERATOR 'S CERTIFICATION : I certity the materials described above on this manttest are not subject to federal regulations for reporting proper disposal d Hazardous Waste .
Generator's/Offeror's Printed/I' yped Name Signature Month Day Year
0 Export from U.S. Port ot entry/ex,·~·------------------
ffi 16. Transporter Acknowledgment ot Receipt of Materials
Ii; Tran sporter 1 Printed/Typed Name
0
Q.
Date leavi U.S.:
Signature Month Day Year
"'----------------------------''-----------------------'---.1----'---~ Transporter 2 Printed/Typed Name
~
17a. Discrepancy Indication Space
1
17. Discrepancy
~ 17b.Altemate Facility (or Generator)
..J
0
Oouantity □Type
Signature Month Day Year
OResidue 0 Partial Rejection 0 Full Rejection
Manttest Reference Number:
U.S. EPA ID Number
~ Facilr 's Phone : fil l-1""1'"'c.""s'"'igna:..c.c.;tu"-rec:.ol'-Alt-ema-te_F_act_l_ity_(_or_G_e_ne-ra-tor_) _________________________ __. __________ M_on_lh __ D_a_y __ Y_ea_r_
!it ~--------------------------~~-------------------~--~-~--
ID
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l 18. Designated Faciity Owner or Operator. Certification of receipt of materials covered by the manHest except as noted in Item t7a
Printed/T yped Name Signature Month Day Year
TRANSPORTER #1
----
~CH REGioNAL LANDFI LL 801:-924-6540 SITE u I TICKET .t .1.u,u.,~,. CELL
N Rowley Rd-North Skull Valley, UT 84029
WEIGHMASTER Asn1ey H .
' .,.,, no ,
( CUST::>MER Gr ayMar Snvi r o nmenta l DATE/TIME IN TT.J / L .J J.L ::,q pm DATE/TIW r;;l1/# j l : l I pm
Att n: Accou nts Payable
Tooele , UT 84 07 4 VEHICLE l>rdy ·,ar:>L <'. CONTAINER
Contrac t :4 1862323 1 1 REFERENCE « ia1>
Generato r:fe dE x Gr o und BILL OF LADING
l -· .. ·-I' u '-rl LC. .LI, '-'"U~63, 300 N t'..l T UNc, lT .3 4 ..1.1 ·~...,.....,~ I V '\
SC AL E OUT TARE WEIGHT 40 ,620 NET WEIGHT 22 ,68 0 INV OICE
\. ./
QTY._ -UNIT:.J -DESCRIPTION RATE EXTENSION TAX TOTAL \ -~
11 . aq t r SW-CO NT W/FU EL Orig i n:UTAH 100 %
l.OD EN VIRONMENTA L FEE l
1. ob FUEL RE COV ER Y FEE
Signature
\,_ Th~ I• ".0 ,~ -or h, ,_, ____
,11 .1. t11
TENDERED
The undersigned lnd1vldual signing this document on behatf of Customer acknowledges that he or she has read and understands the terms and conditions CHANGE
on the neverse side and that he or she has the au lhorlty to sign this document on behalf of the customer. ' CHECK# I
RS-F0 42UPR (04 119 ) Sl(;NATU1E \,_
-------
a:
0 !« a:
5. Generator's Name and Maiftng Address
Generators Phone :
6. Transporter 1 Company Name
7. Transporter 2 ~ny Name
8. Designated Facility Name and Site Add/ess
9. Waste Shipping Name and Descnption
1.
2. Page 1 of 3. Emergency Response Phone
Generator's Stte Address (if different lhan mailing address)
0 THS T
10. Containers
No . Type
&4
U.S. EPA ID Number
U.S. EPA ID Number
U.S. EPA ID Number
11 . Total
Quant ity
12. Untt
WtNol .
2 0 0 0 0 0
w1----1----------------------------+-----+---+------+--+----'-------z w
C>
2.
3.
4.
13. Special Handltng Instructions and Additional lnfom,ation
14. GENE.RATOR 'S CERTIFICATION : I certity the materials described above on this manifest are not subject to federal regulations tor reporting proper disposal cf Hazardous Waste .
Generator's/Offeror's Printed/Typed Name Signature Month Day Year
~ 15. Int ernational Shipments D Import to US .
~ Trans
D Export trom U.S Port ot entry/ex,,'"·------------------
Date leavin IJ.S.:
ffi 16. Transporte r Acknowledgment of Receipt of Materials
le Transporter 1 Printec1'T yped Name
0 c..
Signature Month Day Year
tll --------------------------~--------------------~--~-~--~ Transporter 2 Pri nted/Typed Name
a: I-t 17 . Discrepancy
1
17a . Discreparcy Indication Space
~ 17b. Allemate Facility (or General0<)
..J u
Dauantity □Type
Signature Month Day Year
□ Pa rl!al Rejection □ Full Re jection
Manrtesl Reference Numbe r.
U.S. EPA ID Numbe r
~ Facili 's Phone . fil 1-1-7-c.~Si ..... gna-tu'-re..;.o;...f A-lt-em-a-le_F_a_cil_ity_(_or_G_e_ne_ra-t0<_) _________________________ __._ __________ M_on_th __ D_a_y--Y-ea-r
!« ~--------------------------~--------------------~--~-~--
iii w
0
! 18. Designated Facility Owner or Operator. Certification ot receipt of materials covered by the manrtest excepi as noted in Item 17a
Printed/Typed Name Signature
TRANSPORTER #1
~onth Day Year
r SITE WMJUCH REG~'OT=9"2FS-
8833 N Rowley Rd-North Skull Valley, UT 84029 ,
CUSTOMER
SITE TICKET I CELL
WEIGHMASTER
DATE/TIME IN pm r a y Ma r En vironmenta l
Ac c n: Acco un t s Payable
Tooele , UT 8 4074 VEHICLE CONTAINER
I
QTY,
Co n c r a ct :41 8 623270 5
e n e ra tor :redE x Gr o und
DESCRIPTION
WI\S TE-LlQUI D On grn: UTAH 1 00%
ENVIR ONM ENTAL FEE l
1.0 FUEL RE CO VER Y FE E
REFERENCE
BILL OF LADING
RA.TE EXTENSION
' HIB"" ""l s;gnature '..OUC business -----------
1
The undersigned Ind ividual signing this documenl on behalf ol Customer acknowledges that he or she has r ead and unders!Jlnds the terms and conditions
on t he reverse side and !hat he or she has the authority to sign this document on behalf of the customer.
I
INVO I CE
TAX
RS-F042UPR (0411 9 1 SIG NATURE _____________________ _
pm
TOTAL
TENDERED
CHANGE
CHECK #
a:
0 ~ a:
5. Generator's Name and Mailing Address
Generat:ir's Phone :
6. Transporter 1 Company Name
7. Transporter 2 Company Name
8. Designated Facili1y Name and Site Address
9. Waste Shipping Name and Description
1.
2. Page 1 of 3. Emergency Response Phone
Generator's Site Address (tt different than mailing address )
10. Containe rs
No. Type
U.S. EPA ID Number
U.S. EPA ID Number
U.S. EPA ID Number
11 . Total
Quantity
12. Un it
WtNr:,.
Wi---1-------------------------------+-----+---+-----+----+-----------z w
C,
2..
3.
4,
13. Speciql Handling Instructions and Adcitiooal lnlormation
14. GENERATOR 'S CERTIFICATION : I certify the materials described above Oil th is manifest are not subject to federal regulations for reporting proper disposal d Hazardous Waste .
Generato r's/Otfero r's Printed/Typed Name Signature Month Day Year
~ 15. International Shipments D Import 10 U.S. D Expor1 from U.S. Port of entrylexi~· __________________ _
~ Trans · s onl :
ffi 16. Transporter AcknoY~edgment of Rece ipt of Materials
le Transporter 1 Print ed/Typed Name
0
II.
Da le leavi U.S.:
Signature Month Day Year
"'1-------------------------------'------------------------'-----'---'---~ Transporter 2 Pri nted/Typed Name Signature
a:
I-t 17. Discrepancy I "' ,.,.,.., -"'"
~ 17b. Alternate Facility (o r Generator)
::::i
~ ... -
Douant1ty □Type
Month Day Year
D Residue D Partial Re jection D Full Ae jectioo
Manttest Reference Numbe r.
U.S. EPA ID Number
Facir s Phone : ffi 1--17--c._S,..ig-na-tu""r--e'-of_A_lte-rna-te_F_a_cil-ity_(_or_G_ener __ ato_r_) ----------------------------'~---------M-o-nth--D-ay--Y-ea_r_
~
t5 1------------------------------'-----------------------'----'---'---
cii w
0
118. Designated Facility Owner or Operator. Certification of receipt of materials covered by the manifest except as noted in Item 17a
PrintedfT yped Name Signatu re
TRANSPORTER #1
Month Day Year
~Jl;TC!rRE"GT~FIIL7 HJT-=92,;i -
8833 N Rowley Rd-North Skull Valley, UT 84029
CUSTOMER Gr ayMa r Envi r o nme nt a l
Attn : Accounts Pa y ab le
Tooele , UT B4 07 4
Contract :41862 32705
Generator :FedEx Grou n d
SCA LE OUT TARE WE I GH T
QTY .,
4 2 ,980 NE T WE I GH T
DESCRIPTION
WASTE-L IQ UID Or i g i n :UTAH 1 00 %
FE E 1
FUEL RE CO VE RY FE E
SITE TICKET I
WEIG HM AS TER
OATE/TI M E IN
VEHICLE
REFERENCE
BILL OF LA DIN G
33 ,6 6 0
Signature __________________ _
CELL
CONTAINER
RATE EXTENS ION
The under.signed Individual signing this document on behalf of Customer acknowledges lhat he or she has rea d a nd und e rsta nd s th e terms and conditions
on the rever se side and that he or she has the authority to sign th is document on behalf of the customer
INV OICE
TAX
RS -F042UPR (04/19 ) SIG NATURE ___________________ _ "
am
TOTAL
NET AMOUNT
TENDERED
CHANGE
CHECK#
/
a:
0 ~
Generat or's Phone
6 Transporter 1 Company Name
7 Transporter 2 Company Name
8 Designated Facity Name and SIie Add ress
9 Waste Shipptng Name and Descript,on
1.
2. Page 1 of 3 Emergency Response Phone
Genera tor's Sile Address (if different than mailing address )
10. Containers
No. Type
U.S EPA ID Number
U.S EPA ID Number
U.S EPA ID Number
11 Total
Quanbty
12 Uni1
W!Nct
ffi l--1-------------------------+---+--+----+---+-----'--_.;..-z w
"
2
3.
13 Specia l Handling lnstndions and Adortional Information
14. GENERATOR 'S CERTIFICATI ON : I certify the mate nals described above on this manffes1 are nol subjeci o federa l regulations fol reporung proper disposal d Hazaroous Waste .
Generator's/Offerors Printed'Typed Name Signa ture Month Da y Year
--' 15 . International Shipments
~ □ Import lo U.S 0 Export from U.S Port of entry/exi,._· _________________ _
a: 16 Transporter Acknowledgment of Receipt of Materials ~
0
C.
TranSl)O(ler 1 Pmte<YTyped ame
Date feaVI U.S ..
Signature Month Day Year
! r.-Tr-an-sporte--:-r-=2-:::P:--nn-:-led'T~y-ped~Name::--------------------'-::,Si,..gna-tur_e _ __;_ _______________ _,__Mon_th__.__Da_y__.__Y_e_ar-
a::
t--
17a Discrepancy trxhcat!OO Space D I t 7 Discrepancy
~ 17b Attemale Facility (or Genera1or)
..J u
Ouantny □Type O Resldue □ParoaJfleiect,on □ Full Retect!O!l
Man ile S1 Reference Nu mbe r:
U.S. EPA ID Number
~ Fac,f s Phone . @ t-:-:11"'c "=s,gna~7tu"-re=of':--:-:Al:--ema-te-F=-actty-::--(:-Of--:Ge:--ne-ra-t0f--:)---------------------------'---------..,.Mon-th--D,,..a-y--Y-e-ar-
~ t5 1---------------------------'---------------------_,_ __ ..,__ _ _._ __
iii w
C
! 18 Designated Facility Owner or Operalor Certlficat!OO of receipt of matenafs covered by the manifest except as noted In Item 17a
Pnnt ed/1' yped Name Signat ure
TRANSPORTER #1
Month Day Year
~'lfAS~"l'CtMU:GT~FrI;I;c!0l-=92·r-13 I 88 3~ N Rowley Rd -North Skull Val l ey , UT 84029
CUSTOMER Env i r o nm e nta l
n : Ac c o unts Pa yab l e
7ooele , UT 8 4 07 4
Con t r ac
Genera to r :Fed Ex Gr o u n d
: . 0 .
. '.)q
ENVIRONMENTAL FEE
FUEL RE COVER Y FEE
DESCRIPTI ON
Or i gin:UTAH 1 0 0 \
SITE VJ.I TICKET,
WEIGH MASTER
OATE/TIME IN
VEHICLE
REFERENCE
BILL OF LAOING
Signature ___________________ _
Tb.an!(
CELL
CONTAINER
RATE EXTENSION
The undersigned individual signing this document on behalf of Cu•tomer acknowledges that he or she has re3d end understands tho terms and conditio ns
on the reverse side and that he o r •he nu the authority to s i gn this document on behalf of the cuatomor.
IN VOI CE
TAX
RS-F042UPR (04 119\ SI G NATUR E ____________________ _
pm
TOTAL
TENDERED
CHANGE
CHECKI
,
a:
~
l!i ;
NON-HAZARDOUS
WASTE IIAIIFEST
5. Gel~~
,.,,..,-.,._ rr-"",...V "°'"" ,~ IUUU l"t:.UCA Ul"'llVt:.
MOON TOWNSHIP PA 15108
Generalol's Phcne: 440 708-4001
6. Trnpo!1er 1 ~ Name
Graymar Environmental
7. Trampooer 2 ~ Name 8.~~--
8833 Rowley Road
Nor1h Skul Valey UT 84029
F . , ,5 Phone: [phone]
9. Wa.sle Sh~ Name and De9aiption
1. on-r ma a
2.
3.
4.
2. Page 1 of 3. Emaiganc;y Aasp(la Pio-.
1 440-708-4001
~~IMl mafllgdhss)
720 NORTH 400 WEST
NORTH SALT LAKE UT 84054
004
U.S.EPAl>lunber
WAH000055713
U.S. EPA 10 lunber
U.S. EPA ID Nllrmr
U T 5 0 1 R 2 0 0 0 0 0
10. Conlailels 11.TOIIII 12.Unit
No. Type au.dy WINol .
001 C!Yl JO y
a: 16. Transporttr ~ d Receipt ol MalBrials S Tranaporter 1 Prin1eo'Typed ~ Sigrl8blle Month Day Year
2 3 :l ;Js J l-:~:-ransporle!-.,.......,,..2 -="'PmtecVT~=-yped......,..,.Name:---_,--.......L-...1.-u..,~~=----...L-::----.:......,f-£1C:;...%..--------.........L.-:-:-Monll....,-L.....,,-~--';;,;y;:::ea:.....r
~ · ~ 8 z~
1
17.Disc,epaocy
17a . Oi;aepency lndicaoon Space □Quanliy □ Partial Rejection 0Fu1Rejectioo
MnestRe!lllnceturbr:
17b. AAemal& Facily [or Generalor) U.S. EPA ID lunber
Faci · s Phone:
17c. Siptufll of Alemale Fdy (or Generator) Md, Day
. Celtificatioll of ~ cl materials COV8l9d by 1he mriesl
~~'l'eH-RE~M:.~P'ILL 8 0 1:-92-4-=13·5'"¢
I --88 3 3 N Rowley Rd-North Skull Valley, UT
cu~OMER GrayMar Env1ronmenta
Attn : Accounts Payable
Tooele , UT 84074
Contra c t :418 62327 05
Ge n erat o r:fedEx Ground
TARE WEIGH T 42 ,480
84029
NET WE IGHT
i q i n:UTAH 100 %
ENVIRO NMENTA L FEE
FUEL RECOV ER Y FEE
SfTE TIC KET I
WE IGHM ASTER
D ATE/TIME IN
VE HIC LE
R EFERE NCE
BILL OF LADING
18 ,360
Signature _____________________ _
Than ~ you for ~our busine_s~.
CELL
CONTAINER
RATE EXTENSlON
The undersig ned Individual algnl ng th is docume nt on beh&II of Customer acknowledges that he or aha has read and underatands the terms and conditions
on the reverse side and tha t he or she has t he authority to sign this document on behalf ol the customer.
INVOICE
TA.X
RS-F04 2UPR (04 •19 ) SI GN ATUR E ____________________ _ '-
TOTA L
NET AMOUNT
TENDERED
CHANG E
CHECK I
ex:
~ < a:
s. Generators Name ;m Maili(lg Address
Generator's Prone :
6. Transporter 1 Company Name
7. Transporter 2 Company Name
8. Designate<j Faci lity Name and Sne Address
9. Waste Shipping Name and Descriptioo
1.
2. Page 1 of 3. Emergency Response Phone
Generators Site Address (II difleren1 than mailing add ress)
10. Containers
No . Type
U.S. EPA ID Nlmber
U.S. EPA ID Number
U.S. EP A ID Number
11 Total
Quantity
12.Unit
W!Nri
Wl--4..,...----------------------------t----+---+----t--+--------ffi 2.
Cl
3.
4.
3 Special Handling lnslruclions and Additional lnloona lion
14. GENERATOR 'S CERTIACATION: I certify the materials described above on lhis manifest are not subject 10 federal regulalxlns for reportilg proper <isposal d Hazardous Waste.
Gene ra tor's/Offerer's Printed/Typed Name Signature Month Day Year
..i 15. tntemal!OOal Shipments
~ D Export from U.S. Port of entry/ex,, ________________ _
Trans
ffi 16. T ransponer Ackno'll1edgmenl of Receipt of Materials
le Transporter 1 PrintedlT yped Name
0
Cl.
Date leavi IJ .S ..
Signature Monlh Day Year
! t-:r=-ra-nsport--,-e--,r 2=-p=-m-:-tedff-:-:::-yped--:-N:-:-am-e ________________ __,_-=s.,..igna--:-tur_e _________________ L.,M""on.....,...th -'--c-Da_y_.__Y,..ea-r
ex: ....
1
17 . DISCrepancy
17 a. Discrepancy lnd'cation Space
00uan1rty □Type 0Resldue 0 Partial Rejedlon 0 Fuff Rejectioo
Mamest Reference umbe r.
~ 7b . ema e Facitny (or Generator) US EPA ID Number
..J
~ t-f_aal__.._s_P_hone_: ________________________________ ......._ ______________ _
0 17c. Signature of Mernate Facility (or General ~ Mooth Day Year
~-----------------------,----~------------,--------~-~--..._-
iii w
0
118 Designated Facility o,.,,,,,er or Operator. Certification o1 receipt of materials covered by !he manifest except as noted 111 Hem 17a
Printeo'Typed Name Signature
TRANSPORTER #1
!.onth Day Yeai
"si'TEWM-A~G-~P'Tt.L 801 =924 --e 5"40-
88 J3 N Rowley Rd-Nor th Skull Valley, UT
'>---,nu<l 1
CUST0"4E R ·;rc1y M..,r Er:•: _ro n:ne n ta l
A:tn : Acco•.:nt s Pa yable
'I'ooele, ll'T fl~074
-----
84029
SITE TICKET f -1en1>'98 'ceLL
WEIGHMASTER r\
DATE/TIME IN ..17~1-/':
VEHICLE CONTAINER
REFERENCE
,d lt nv--------..L.------------------1
....
\..
\__
r;J ;.trc1(:· : ~186:?3:?705
Se;e rator :FedEx ~r ound
B IL L 01' L ADIN G
TNROIJN-D ~CO.L E H ' GROSS WE IG HT 16 /11 0 Pl C:P tpOI IS f 1 • .,g INV OI CE
78 0
'\
Ot.SCfUPTIOff RAT!! .. 1 EXTENSION , TU I TOTAL 4
S W-SPE!:IAL lol\.STE-L!:QUID O rioi n :U:'/\H lO Ot
EN\'lRotlMENTAI. rEF. •
FUE ~ PECOVERY FEE
Signature _____________________ _
Thank _y ou for ~ou r business ---------
Tl>e uoder1lgne<1 1no 1¥1<iua1 119nlng this document on bellafl ot Cu11omer "i\'.no~ges tnat ne or 1M nos reeo end unde1'9tands the terms end condition•
on tt•• ,.,,.,_ tH'.le and Chat he o, •he hH th• 1uthor,ty to 1190 thl$ document on behalf ol Iha customer.
RS-F:J~2UPR (04'191 SIGNA TU RE _________________ --
T ENDERED -CHANG E
_,/
a:
0 ti a:
Generator's Phone:
6. Tran sporter 1 Company Name
7. Transporter 2 Company Name
8. Designated Facility Name and Stte Address
Facifi ·s Phone :
9. Waste Shippi1g Name and Description
1.
2. Page 1 of 3. Emergency Response Phon e
Gene rator's Stte Address (rt different than mailing address)
10. Containers
No. Type
U.S. EPA 10 Number
U.S. EPA ID Number
U.S. EPA ID Number
11. Total
Quantity
12 . Un tt
WtNol.
Wt-----t-----------------------------+--------+-----+---+----------z w
Cl
2.
3.
4.
13. Special Handling lnstn.dions and Addrtiooal Information
14. GENERATOR 'S CERTIFICATION : I certify the materials described above on th is manttest are not subject to federal regulations for reporting proper disposal d Hazardous Waste .
Generator's/Offeror's Printed/Typed Name Signature Month Day Year
..., 15. lnterrationa! Shipments 0 i-Import lo U.S.
~ Tran
ffi 16. Transporter Acknowledgment ol Receip t of Materials
Ir Tran sporter 1 Prjnted/T yped Name
0 c.. ,I
0 Export from U.S. Port of entry/extt_· _________________ _
Date leavi U.S.:
Signature Month Da y Year
1/) 1-=---,----:--::--:-.,--,,=--:-:,-----------------------'--=:----:--------...:_----------'---.J'--:---L..-,---~ Transporter 2 Printed/Typed Name Signature Month Day Year
~ t 17. Discrepancy I ". -...... -□ °"''"'
l: 17b. Alte rnate Facility (or Generator)
:;
~LL-
f acir s Phone :
O rype OResidue 0 Partial Rejection 0 Fun Rejection
Manttesl Reference Numbe r.
U.S. EPA ID Number
fil r-:::17:-c-::S':--igna-,-tu-,e-o7f Ah-:-:--ema---,-te-F=-a-:ci::clity-(:-or--:G:-e-ne-ra7to..,r)-------------------------~---------.,..,M-on--:th---:O:-a-y-..,.Y,...ea-r-
~ ts 1---------------------------''---------------------....J..--l..--....L.--u; w
0
l 18. Designated Fae1lily Owner or Operator. Certification of receipt of materials covered by the manifest except as noted in ttem 17a
Printed.IT yped Name Signature
TRANSPORTER #1
Month Day Year
---_______________ ..__. ___________ ...., __
· SITE WP,3ATC~~80-1 -'924 -8·!,,
8 8 3 3 N Rowley Rd-North Skull Vall ey , UT 84029
~ _ _J.._wo ~
CU STOMER (;ra v ~•;ir •nv1ro rn1,C!!Ld l
,itu1 : A.c c o u:1 ts Payah l @
!ocele , ur q c07 4
:;enP.r ·n ;•u n
SI TE v -l TtCICET• l:-O'li.--7 CELL
WElGHMASTER ,.
DATE'TlME IN
VEHICLE CONTAINER
REl'!!RFNC E ~---+la-r+~
BILL Of LADING
llET T{)NS f 3 . Jt AANI-J.Ab--4~J GP06S WEIG H':' 6J • 000 NF,'r t•ll:; I GHT """' , .... ,.,,., INBQU [J G• "\
t
:'6 , 60 0
f ''"'! Pl "''I "l"r ,,.-,ong urY DESCRIPTION I RATE I E.lCTENSI ON I TAJ! I TOTIU. '\
ur o Origi~:~TAH lO Ct
Signature _____________________ _
Tha nk you fo r1 vou r busin,..!!e;;.:s~s._ __________________________ _,_ ____ _._ ______ _._ __ _
Tho unriers•Qnl.'O lnd 1vtd ua1 slgn\nq rh la doeu-nt on behalf of Cuatomer ac,-nowledgN that ~e o, ahe has re.ad and undcn!Jlnds lhP terms nnd condlOoos
on IM "'""'H ••d• and lhal h • o r sh e h H 11,e a ulhorlty to sl911 Ihle document on bchnll nl thn r.usloffll'r
Rl).J;:i lJlJPR '1 9 , SIGNATURE ___________________ _
, ( :,,,.,8·1114 I
TENDERED
CHANGE
CHECI<•
'-