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4 n E!v —1 r' 'Z / _C' Form Approved OMB No. 2050-0039 <br />Please <br />print or ly e. (Form designed for use on elite (1 [•pucrl) Pewwr' 4. Manifest Tracking Number <br />2 Page 1 of 3. Emergency Responso Phonr. 8 <br />t. Generator tD Number <br />UNIFORM HAZARDOUS 004823738 JJ K <br />WASTE MANIFEST cAL00027MM 2 800-424-9300-CHEMTREC <br />Generator's site Address (if different than mailing address) <br />S. Generator s Name and Mailing Address <br />PROFLEET, INC. - LODI 15453 N. THORNTON ROAD <br />9050 ELKMONT AY LODI, CA 95242 <br />ELK GROVE, CA 96824 <br />Generator's Pho U.S. EPA 10 Number <br />8, transporter 1 Company Name CARD00171017 <br />FREMOUW ENVIRONENTAL SERVICES INC. Phonety 800-55i}3274 <br />US EPA ID Number <br />7, Transporter 2 Company Name <br />21st CENTURY ENVIF OAMENTAL MANAGEMENT OF NEVADA, LLGCARD00164012 <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />21ST CENTIJIl tY EMI M/D980895338 <br />2095 NEWLA 4DS DRIVE, EAST <br />FERNLEY, NV 69408 <br />Facilit <br />es Phone: mn <br />9b. U.S. DOT Description (kxJud'ng Proper Shipping Nam Hazard Class, ID Number, <br />10 Containers <br />11. Total <br />Quantity <br />12. Unit <br />WLNoI. <br />13 Waste Codes <br />No. <br />Type <br />ga <br />HM <br />and Packing Group (ir any)) <br />t. Nor►-RCRA Hazardous Waste, Solid ( ly Debris) <br />, <br />DM <br />ZW <br />P <br />223 <br />I <br />WZ <br />W <br />2 <br />(9 <br />4. <br />i <br />14. Special Handling Instructions and Additional Information <br />Handerls to be 40ty trairmol and use PPE. <br />9b1) 388188-00 I XS511% <br />ERG # 171 <br />t5. GENERATOR'910FFEROR'SCERTIFICATION: thereby d <br />are that No contents of this amsignment are fully and accuraley described above by the proper shipping name, and are classified, packaged. <br />infomadonat national rogulalions. If export shipment and am the P maty <br />marked and labetedlplecareled, and are In an respects In prop <br />r condition for transport according to applicable and governmental <br />Exporter, I certify that the contents of this consignment conform <br />to the terms of the attached EPA Acknowledgment of Consent. <br />I cediy that thy waste rninimizallon statement identified in 40 <br />FR 262.27(a) (! I am a large quantiy generator) or (b quantity generator) i e. <br />Month Day Year <br />alor Rerof PdntedrT N <br />gnalure <br />0 07 ol <br />Wt C <br />—j <br />- <br />'16.1rilemaknal Shipments In l"mport to U.S. <br />Transporter signature (for exports only): <br />1 _ I Export from U S. Port of entry/exit - <br />Date leaving U.S.: <br />17. Transporter Acknowledgment of Roo"I of Materials <br />Month Day Year <br />' <br />Sitar) nl yped Name <br />T <br />Signature <br />DS 0 Or) <br />(` i <br />Signa Month Day Year <br />Tr sporter PMtedrryped Name <br />18. Discrepancy <br />tea. Discrepancy Indication Space 0 Ouamily <br />71 Type, as due ❑ Padial Rejedion ❑ Full Rejoclkln <br />Manifest Reference Number. <br />leb. Alternate Facility (o(Generalor) <br />U.S. EPA ID Number <br />U <br />FacAys Phone: <br />Month Day Year <br />W <br />1Be. Signature of Altemalo Facility (or Generator) <br />2 <br />19, Hazardous Waste Report Management Method Codes (.e., oo(es <br />for hazardous waste treatment, disposal, and recycling systems) <br />� <br />1 2 <br />3 4. <br />(4) <br />20. Desigreted Fadhly Owner or Operator: Certification of receipt of <br />hazardous materials covered by the manliest except as nded'n Item 18a <br />ye <br />i�ted yped Neme `'(' ((r,' <br />Signature filen Da Y <br />5 <br />W 1. ill Qr <br />�• <br />aUIFiED.' <br />EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILIV TO DESTINATION STATE (IF qE <br />