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1700 S. Cherokee Ln, Lodi, CA PR0513687 <br /> 04/21/2022 Program: HW <br /> PHOTO 12: <br /> Missing final signed co of manifest(Corrected on site) <br /> . <br /> 'A0DJ1P0 <br /> d NnoonNEpSoit cen ramnDNumbCAL2000 �_ M <br /> OV <br /> N�SC Nend TMuFlsling Address f zPaga <br /> \` <br /> Faml q <br /> J n Chet•okee Ln 0 a.MJmJl+usr uaskm Nmberoved.OMB No.2050.0039 <br /> Dp fid' canna-'s siteAddress(Itdmeremtharire11gatlare!7 915 <br /> joo-�(�lunooDl�I XD� c ��sPh� 209-340-g5 0 SKS <br /> 6£Z-60Z 08 CR 95240 7802 <br /> ECO£- 0L08-6bZ-60Z }, `fS° Rf 5Y3?EM6 Iry� <br /> rz8-008" u�pW 'N 5L5L Trensporter2CompanyName <br /> ,tea}UDW }aa.i4$ CLEAN FlRR80RS ENV SVC u.sEPAIDNnmber <br /> y AO:) VIA 9.Designated FacilityNameandSlleENIV INC' TxRoaaaelzes <br /> kCljLN■• „,// CLEANHARBORSU ..Scucumber <br /> 2800 LOKE OF BUTIONWILLOW <br /> Facility's Phone: MRDa39322z59 <br /> 661_762—f'200 B1�7TONWILLOW ROAD DS EPA ID Number <br /> ga. 9b.U.S.DOTDescrip1oI (dudin P ' CA 9'206 <br /> HM and Packing Group(itany)) g roper Shipping Nam e,Hazard Class,ID Number, CAD980675276 <br /> K t NA 07-7(CHRbMIUMARD0l1$ o.conama n Teml 12 wit <br /> WASTE C No. Type Qdmuty WtNL <br /> 3 Wase Codes <br /> Qq , L.EAD), ga u01_,A, N.0 33. <br /> „a III CM -Ltd P D001 D0a7 DZZO <br /> w 2 <br /> c7 141 <br /> 3. <br /> 4, <br /> 14.Special Handling InsWctionsand Additional Information TSD n BL 85725050 L024049 CSI: <br /> i)ER6#171 <br /> 24H EMk'.R1117-NCY#1500-468'176@—CM/SK/TFI—Contract retained by generator confers a ency authori y <br /> on initial t^an or'ter t add r G titr ddit' n 5 <br /> 15. GENERATOR'S70FFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and allUMtely described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable Intemational and national governmental regulations.It expert shipment and 1 am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the erected EPA Acknowledgment 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 true. <br /> Generatols/Oderofs Prinledrrype[dd Name Signature , y- Month Day Yes, <br /> �GC✓t, <br /> 16.Intemabonal Shipments ❑Ex rtfrom U.SPort of en <br /> . bylexif. <br /> ❑Import to U.S. Po <br /> ? Transportersignature(for exports only): Data leaving U S.: <br /> C 17.Transporter Acknowledgment of Receipt of Materials <br /> W Signatu Monty Day Year <br /> Transporter 1 PnntedfFyped Name <br /> D, a :> <br /> a �r - � � <br /> FM N Day Year <br /> Qi Transporter 2 Pnnled/rype ame ` nd10 e <br /> K <br /> k— <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space puanliry E]Type El Residue <br /> ❑Partial Rejection 13 Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> J <br /> U <br /> kai Facility's Phone: Month Day Year <br /> W 18c.Signature ofAltemale Facility(or Generator) <br /> a <br /> z <br /> ti19.Hazardous Waste Report Management Method Codes b,e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> ril 1 2. 3. 4. <br /> 0 <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as in Ed in Item 18a Month Day Year <br /> Pnnted/Typed Name Signature <br /> EPA Form 8700-22(Rev.12-17�Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br /> 1)7:f7c'c3�9/944459 <br /> r <br /> VICKY VANG-LEE, REHS Page 12 of 14 <br />