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1 <br />lvoew/I ` O / /, 806694 76022 <br />' <br />Please onnt or tvoe. (Form designed for use on elite (12-o,6) riter. �O T 1 Form Aooroved. OMB No. 2050.0039 <br />i <br />w <br />C <br />EPA Form a/UU-22 (Hev. HreAous editions are obsolete. DESIGNATED FAdILITY TO GENERATOR STATE (IF REQUIRED) <br />t o - 0;o`I Ar10260.0986� <br />I <br />UNIFORM HAZARDOUS <br />1. Generator 10 Number f <br />2. Page 1 of <br />3. Emergency Response Phone 4. Mani%st Tracking Number <br />WASTE MANIFEST <br />CAMM143 76 <br />1 <br />800 567-745' 0 0 3 3 7 4 9 4 8 JJ K <br />5. Generator's Name and Mailing Address Generator's Site Address (d different than mailing address) <br />:LODI CHIOHE LODI CBIOIR <br />316 A. RAIN STRKff 316 H. HAIR STii Y <br />Generatoh=ngA 95241 289 368-4691 - LODI CA 95241 (219)368-4691 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />21st CENUMY EM CMWO164012 <br />7. Transporter 2 Company Name U S. EPA ID Number <br />n _ <br />8. Designated Facility Name Jnd Site Address U . E A ID Number <br />21st Century fl1I <br />2195 Newlands Dr. bast <br />Facifityrs Phone Yernley, BV 89418 ( 775) 515-2761 NVD980895338 <br />ga <br />9b. U.S. DOT Description (inducting Proper Shipping Name, Hazard Class, ID Number, <br />10 Containers <br />11. Total <br />12. Unit <br />13. Wade Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) 1 <br />Quantity <br />yytNol. <br />1. HAZARDOUS WASTE, SOLID, N.O.S. (CHIOHIUH, LEAD) 9 NA3177 PGIII <br />0111 <br />D118 <br />181 <br />o <br />X <br />RQ(0118) <br />BA <br />P <br />z. AOH-RCRA HAZARDOUS WASTE LIQOID <br />C <br />132 <br />w <br />TP <br />,�13 <br />G <br />3 .. . <br />- <br />r <br />4. <br />14. Special Handling Instructions and Additional Information <br />(1) 371651-01 - EIG(171) FLOOR WASTE SOLIDS (2) 124987-11 - RINSE WATER <br />15.. GENERATOR'SrOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately 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 trensport 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 Acknowtedgment 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 ( I am a small quantity generato e. <br />Generato(s/0liercrs Pnnted/Typed Name Signature Month Day Year <br />L- D <br />16.International-Shipments f <br />❑ Import to U.S. El Export S. :.—ent ry/exrf <br />Transporter signature (for exports brdy): to lean ng U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />IX <br />Transporter 1 Printed(Typed Name Signature Month Day Year <br />0all <br />9 71,ja <br />S <br />YIJL�' <br />Z <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />-7 <br />e r Y <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ ❑ ❑ Rejection ❑ Full R ecton <br />❑ Quantity Type Residue Partial el <br />` <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />tai <br />Facilitys Phone - <br />U0 <br />18c. Signature of Alternate Fadity (or Generator) <br />Month Day Year <br />Q <br />, <br />Z <br />y- <br />19. Hazardous Waste Report Management Method Codes Cie`., codes for.ha�aardotis'waste treatment, disposal, and recyding systems) <br />0 LLA1 <br />2I_l <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 />PrintedrTyped Na Signature Month Da Ye <br />a'n VT <br />EPA Form a/UU-22 (Hev. HreAous editions are obsolete. DESIGNATED FAdILITY TO GENERATOR STATE (IF REQUIRED) <br />t o - 0;o`I Ar10260.0986� <br />I <br />