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1700 S. Cherokee Ln, Lodi, CA PR0513687 <br /> 04/21/2022 Program: HW <br /> PHOTO 13: <br /> Missing final signed copy of manifest(Corrected on site) <br /> DaP'•' — 7:1_ SN CHIP# 23377881c <br /> S s l �� a <br /> un000���Synod UNIFORM rK.ANZaAreRaDtlOUMSairgAdtress CAI006225554 <br /> p <br /> wForm <br /> Approved.OMB No 2050-0039 <br /> WASfEMANIFEST 6u <br /> r771915 <br /> SKS <br /> �£6£Z-60Z X btiZ_60Z i700 SoCharokee Ln ca�mcseAda sslnamee vrmasnwnessl <br /> ad <br /> LODI CA 95240-7802 <br /> 8-p08-1 0108"uiDW Pl g l51 G� .PNana zea-3ae-8508 <br /> 81ts SYSTEMS INC. US EPAIDNunde <br /> 8 -y.aewar6o:2a� <br /> ►a}uoW } ' US EPAIDNumber <br /> 1N^O TCLN HARBORS ENV SVC INC, ,AD03a 222�Z <br /> �i 1, e_oas�ated Fao.ry N'n'°a"d sne AddCLE.RN HARBORS ENVIROPSNENTAL SERVICES, IN Us E--'- <br /> 2247 S HIGHWAY 71 <br /> 308-235-4012 KINBA1-L , NE 59145 <br /> NE 0581'72351 <br /> FaplAys Phpp'. <br /> ga. ".US. esrn <br /> DOT Dpaon(mckking Proper Slipphg Name,Halal mai <br /> Class,ID Number, 10.Coners 11.Total 12.Une ta.,A,y,a C I. <br /> HM and Pack'Ing Group(d any)) No. Type Quantity wmul. <br /> X 1 041203, WASTE GASOLINE; 3, PG lI t1" 010111D0i8 2. <br /> o l <br /> i z <br /> c� <br /> 3 <br /> 4. <br /> 14.SWaral Handling Instructors and Addmoal lnfonnaron TSD:KP 857251050 1_02404s <br /> 11 ERGtt 128 <br /> 24H EMERG�NCYR900-468--1760-CH/SK/TFI-Contract retained by generator confers aqenter authors v <br /> an initial transporter to add or substitute additional trans orters onpp1nenaaraEor`a behalf. <br /> 76 marked and abelOetl pacceded and are)aAallOrespeds abproperam did forbul anspod accordingto applicableinternationaland ational9ovemmenlal regulations)If exportshipmentand l am the Primary <br /> Exporter,I certify Uat the contents of Ihls consignment conform to the terms of the attached EPA Acknowledgoreornt ob�I amts small quantity generator)Is true. Month Day Year <br /> I mr*that the waste minimization statement Identified in 40 CFR 262.27(a)(It I am a large quantity Signature (P) <br /> GeneratoestOMerors PdntedRyped Names <br /> 16.Intemabonal Shipments ❑Import to U.S. ❑Export from U.S. Port of enlrylexiC <br /> Date leaving U.S.: <br /> Transporter signature(for exports only): <br /> w 17.TrmaporlerAcknoWadgment of Receipt of Materials Signa{e Month Day Year <br /> wra,Transporter l Prime rY d N a �, i <br /> a y,,� ` -5 nalu Month Day Year <br /> QZ <br /> Tininsporter 2 Pdnted/Type.Name <br /> K <br /> r <br /> 18.Discrepancy 1 <br /> 18a.Discrepancy ❑Full Rejection <br /> Type ❑Residue ❑P.mal RejectiDiscrepancyIndication Space �Quantity <br /> Manifest Reference Number. <br /> U.S.EPA ID Number <br /> r 18b.Altemate Facility(or Generator) <br /> J <br /> U Month Dey Year <br /> uta. Facility�s Phone: <br /> U.1 18c.Signature of Altemate Facility(or Generator) <br /> Q <br /> Z <br /> w19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste Natreatment,disp3sal,and recycling systems) <br /> C3 1 2. <br /> 0 <br /> 20.Designated Facility Owner or Operator.Certincalion of receipt of hazardous materials covered by the mSignalurecept es riled in Item 1 a <br /> Month ay I" <br /> PrinledRYped Name GENERATOR'S INITIAL GOPy <br /> EPQ�„�„p�pp����i�12-�1.Pirevious editions are obsolete. <br /> VICKY VANG-LEE, REHS Page 13 of 14 <br />