Laserfiche WebLink
793581 U ( -N L. U <br />From Annmved- OMB No 2050-0039 <br />EPA Fonn 8700 -ZZ (Hev. 3 ub) rrewous editions are ooseiete. DE510NA1 tD IFA(;I fjTY TV GtntrlAI Un a IA I r pr nevurmevl <br />0 7 -10 -10221.1548) 1 N <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />r <br />2. Page 1 of <br />3. Emergency Response Phone4. <br />Manifest Tracking Number <br />001952714 JJ K <br />WASTE MANIFEST <br />, CMOW143776 <br />1 <br />800 567-745 <br />5. Generator's Name and Mailing Address Generatoes Site Address of different than marling address) <br />LODI CnOR); ? LODI CIMOIN <br />316 R. GAIN SyRk4 316 19. RAIN 57M <br />GeneratorhULECAi.35141 (269)368-4691 LODI CA 95248 209(368-4691 <br />6. Transporter 1 Company -Name U.S. EPA ID Number <br />21st CEMURY EM CAR080164012 <br />7. Transporter 2 Company Name U S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />21st Century ®I <br />2195 aerlands Dr. Bast <br />Faciliys Phone: Fernley, Hit 89488 (775) 575-2768 NVU980895338 <br />ga <br />9b. U.S. DOT Description (including Pmper Shipping Name, Hazard Class, 10 Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Patting Group (if arty)) <br />Quantity <br />WtiVol. <br />1.d""Uous wAm, r rmul j Mid <br />R90007) <br />HA <br />Z <br />2. <br />W <br />3. <br />4. <br />14. Special Handling Instructions and Addibonal InfornaJon <br />(1) 378657-08 - IMG(171) FLOOR NASTE SOLIDS <br />15. GENERATOR'SlOFFEROR'8 CERTIFICATION: I hereby dedam that the contents of this consignment are fully and accurately described above by the proper shipping name, and aro ciassifed, packaged, <br />marked and labebdiplacarded, 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 AcluxWedgment of Consent. <br />I centiy that the waste minimization statement identified in 40 CFR 262.27(a) (If I em a large quantity generator) or (b) (if I em a small quantity generator) is true. <br />Gen e/Offeror's Pdn%d/Typed Name S gin re Month Day Year <br />16.Intemational. h enb <br />❑ Importto U.S. El Export from, U. Port of entry/exit <br />- <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />Tyner 1 yped Nam S gnaN Month Day Year <br />a <br />o7 lo 07 <br />Z <br />VTnspwwar 2 Prlmed/Typed Name Signature Month Day Year <br />OC <br />18- Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection <br />Manifest Reference Number. <br />Z <br />J <br />18b. Alternate Facility (a Generator) U.S. EPA ID Number <br />U <br />LL. <br />Facility's Phone: <br />W <br />18c. Signature of Altemate Facility (or Generator) <br />Monty Day Year <br />Q <br />Z <br />H <br />19. Hazardous Waste Management Method Codes (i e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0LLA <br />jRlepoort <br />1 1 1 � <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />N <br />PrinteifTypedSignature <br />( Month Day Year <br />n22Lam�]�'rt-102t/6 <br />101 <br />EPA Fonn 8700 -ZZ (Hev. 3 ub) rrewous editions are ooseiete. DE510NA1 tD IFA(;I fjTY TV GtntrlAI Un a IA I r pr nevurmevl <br />0 7 -10 -10221.1548) 1 N <br />