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lop 776432 <br />FnrmAnnrnveri IGfFT'hTn77090-0039 <br />Please <br />print or type. (Form oesignea <br />UNIFORM HAZARDOUS <br />ioi ear UI. tr LU t 14-v„� ,r I, F-1-11 <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone 4• Manifest Tracking Number <br />001948886 JJ <br />WASTE MANIFEST <br />OW I A -It-7-7j; <br />_, <br />—i " <br />' SiT L <br />I” <br />5. Generatofs Name and Mailing Address Generators Site Address (if different than mailing address) <br />LODI CHROME LODI CHROME <br />316 N. MAIN STREET 316 N, MAIN STREET <br />4691 <br />GeneratonEA 95240 209 368-4691 LO -U.S. EPA 10 Number <br />6. Transporter 1 Company Name <br />OW1 640-12 <br />21St RYA U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />8. Designated Facility Name and Site Address U.S. EPA 10 Number <br />21st Century EMI <br />2095 Newlands Dr. East <br />Fernley, NV 89408 (775) 575-2760 rai�D980895338 <br />Facilily�sPhone: <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13, Waste Codes <br />9s <br />HM and Packing Group (if any)) No. Type Quantity Wl.Nol. <br />1. WASTE TOXIC LIQUID, CORROSIVE, INORGANIC, N.O.S. (COPPER CYANIDE, <br />F007 <br />' <br />0 <br />R <br />SODIUM HYDROXIDE) 6.1 (8) UN3289 PGII 'TOXIC' 2G(154) <br />TP <br />&5M <br />G <br />a <br />Z <br />2. WASTE TOXIC LIQUID, CORROSIVE, INORGANIC, N.O.S. (COPPER CYANIDE, <br />F008 <br />Lij <br />R@ <br />SODIUM HYDROXIDE) 6.1 (8) UN3289 PGII 'TOXIC' ERG(154) <br />DF <br />�G© <br />P <br />3. <br />4. <br />( <br />I <br />14. Special Handling Instructions and Additional Information <br />(1) 366457-00 - COPPER CYANIDE TANK (2) 366458-00 - COPPER CYAaNIDE TANK <br />15. GENERATOR'SIOFFEROR'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 />international and national governmental regulations. If export shipment and I am the Primary <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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 (b) (if I am a small quantity generator) is true. <br />G toe /Offeror's Pr drfyped Name Signa Month Day Year <br />030 <br />1 , a1,12 <br />I- <br />❑ Ex ort from U.S. Part of entrylexit: <br />❑Import to U.S. P <br />= <br />116.Tn—tematlq�/ShipAients <br />Transporter_§ignalure (for exports only): Date leaving U.S.: <br />R <br />17. Transporter Acknowledgment of Receipt of Materials <br />Month Day Year <br />�T <br />© <br />ansport PrinledlTyped Name Xnale ` <br />5�7C> c 7 <br />aTransporter <br />2 Pdnted/ryped Name Signature Month Day Year <br />a <br />i- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. FSA ID Number <br />J <br />V <br />w <br />ear - <br />iBc.Signature ofAltemateFacility (or Generator) <br />Q <br />Z <br />N19. <br />Hazardouss Wasstej Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1 1! V <br />2 <br />4 )q I <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 182 <br />Pdntedrryped Nae Signature Month Day Year <br />hell- a �,� /v o <br />T <br />.. 1.�..-r.i1a� I+T STS riin OC r�1111Qi ::011 <br />EF'A Form 8/UU-22 (ttev, a-uo) rrevtous eaiaons a e ustitele; .I .0 I U 1 D 1J�bfia e'�ii t =W r "AI'Maj 1 1 <br />. <br />