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1700 S. Cherokee Ln, Lodi, CA PR0513687 <br /> 04/21/2022 Program: HW <br /> PHOTO 14: <br /> Missing final signed copy of manifest(Corrected on site) <br /> I,g LL I Please print or <br /> UNIFORM HAZARDOUS 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> 2.Page 1 0l 3.Erne ge oY Re ponse Phone 4 Muni t Tracking Nu;_ <br /> Woo <br /> 1 WASTE MANIFEST - r, i J_J �� OOH <br /> J S.Genemlp'■Name and Mailing Address 36 60Z XCp j bt7 <br /> V t.Jf11 HO[,.Jd Genaralols Site Address(d tliaerem Nan ma l'gaddress) V A4/ <br /> 1J1d[�I ,y Cherokee t_lo <br /> L �� ,uO <br /> LG I IN 0O• <br /> Gerrenspon Phone eH9-eS40-CfebA _ NO � <br /> 8.Transporter 1 Canpany Name O <br /> Z 60Z . _r_;_fN ,S v'--ILM& INC U.S EPA ID Number <br /> w7 Transporter 2 Company Name <br /> •N S S 1 -.. , cJ�L Irj(,• U.S.EPA ID Number <br /> L B.Designated Facility Name and Site Address - - L000.0QypA <br /> 2-5:00 LORBORS OF BU7'r!fl,F i' v! u.s.EPAIDNamber 6�0� <br /> BUTTNWIERN R11FiL 6 £-607 <br /> f1UTTc7ry(•fILLO!•± , CF1 :,'Srh66 {� JC <br /> _ Faciliys Phone: <br /> I ga. 9b.U.S.DOT Descnpfion(including Proper Shipping Name,Hamml Class,ID Number, 10.Containers 17.Total 12.Unit ■ <br /> 1 HM and Packing Group(if any)) 73.Waste Codes C <br /> 1 <br /> No, Type Quantity Wt.Nol. <br /> 2-g :A,I_ L, T4.1.1. <br /> , S, Ptj I �:. N, <br /> U NN�lbiluPl, Lt.' <br /> w <br /> z 2. <br /> ` W <br /> CO r <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSLFBIL <br /> �y7 tMER ;aLlltdbO•-4t;3-17b0-CHiSK/TfI-Contract retained bV generator confers <br /> On ini <br /> r' 1 a -t' �uwc <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare thatthecontentsofthiscon,..ment are fully and accurately described above by the proper shipping name,and are classified.packaged, <br /> J marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. ! <br /> I certify that the waste minlmizaVon 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 /> GeneratoeslOHemrs Phntedrryped Name Signature Month Day Year <br /> 16,International Shipments to <br /> t'— ❑Im portU.S. El Export from U.S. Port of entry/exit: <br /> 'I ? Transporter signature(for exports only). Date leaving U.S.: <br /> K 17,TransporterAcknowul entof Receiptof Materials <br /> Transporter 1 PrintedRyped Name Signature Month Day Year <br /> O <br /> a <br /> ■ Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> H <br /> 18a,Discrepancy Indiction Space ❑Quantity El Type ❑Resitlue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number, <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> G <br /> 1 Facililys Phone: <br /> iM 18c.Signature ofAjortude,Facility(or Generator) Month Day Year <br /> z2 <br /> y 19.Hazardous Waste Report Management Method Codes(I e.,codes for hazardous waste Treatment,disposal,and recycling systems) <br /> 3. 4. <br /> 1 20 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as road in Item 18a Montle Day Vear <br /> Pdntedrl-yped Name Signature <br /> EPA Form 8700-22(Rev.12-17)Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> VICKY VANG-LEE, REHS Page 14 of 14 <br />