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930 E. Victor Rd, Lodi, CA 95240 PR0513645 <br /> 01/05/2022 Program: HW <br /> PHOTO 1: <br /> Manifest has an incorrect EPA ID number and missing fat copy with designated facility's signature <br /> Phase carni iv pe Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS t Gercalar ID NUM ].Pap°1 d a.E"w."q y Resp°"se Pao"° 4'ManlrM(racldnp Numbr <br /> WASTE MANIFEST , nrr f GBF <br /> 5.GananaW,Nam—Wrin,Addrees Site Address IVdiaereM than m M g addreaa) <br /> le,rwrolcrmr l.,r, 930 E VKIL.Rd <br /> 1011 Loa.CA 95240 <br /> Ganaralo(s Phone <br /> 6,Tmneporter 1 Conrpa^/'Name US.EPAID Number <br /> IlldeprxNere:e L'PMruNner4il Sn c,&S.LLC CAR"00305548 <br /> 7,Transporrer 2 Company Name U.S.EPA ID Number <br /> 8.Desipna(ed Faaliry Name and Site Address U.S.EPAID Number <br /> I_i ormeNal Waste-Artlons AZRrJUM20478 <br /> 31015 tndwAfral Ln <br /> 877-227.0180 Parker SrAAh..AZ 13534.1 <br /> Foals Plxme: <br /> ga. so U.S.DOT Devnptrome <br /> n(including Proper Shipping Na ,Hi Class ID Number, 10.Containers it.Total 12.Unit 13.Wasle Codes <br /> HM and Padag Gmup(d any)) No. Type Quantity WLN.L <br /> 1. <br /> o tlx FICRA fta rdovs Waste Llg1Ad(06y,WatFr) rrOt lT ��0� <br /> Q <br /> K <br /> Z 2. <br /> c7 <br /> 3 <br /> 1 <br /> 4 <br /> _ 14.Speaal Handling Instructions and Additional Infomnation <br /> 15. 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,a re classified,packaged, <br /> marked and labeledlplacaded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.if export shipmet and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the tens of the attached EPAAcknoWfedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is We. <br /> Generai ,"1..'�t7r1ramis Pnnaxlff ame NSignatu^re Monty Day Year <br /> lit Z �' <br /> i (7 <br /> F 16.International Shipments ❑Import to U.S. ❑Export from U.S. Portofenhylexd: <br /> r <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> K 17.TmnsponerAcknmWedgn tof ReceiptofMatedals _ <br /> e W grarralpre <br /> � <br /> Transporter 1 Pdntedrryped Name Monty Day Year tt(P.'.7 <br /> Q Transporter2 Phntecirryped Name signature Monty Day la, _ <br /> a C <br /> r <br /> ,k 18.Discrepancy <br /> I 18a,Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Piri Rejection ❑Full Rejecunn <br /> Manifest Reference Number: <br /> 1Bb.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> v <br /> LL Fadlit)'s Phone: <br /> w 18c SignatumofAltemate Facility Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyding systems) <br /> LU i 2. 3. 4 <br /> 1 20 Designated Facility Owner or Operator:Certification of recelpt of hazardous materials covered by the manifest except as noted in Item 1B <br /> Pn(edrPyped Name Signature Monet Day Yann <br /> EPA Form 8700-22(Rev.12.17)Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> VICKY VANG-LEE, REHS Page 1 of 1 <br />