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Please print or type. (Form designed for use on elite (12 -pitch) typewriter. <br />FGenerataes <br />RDOUS 1. Generator ID Number <br />FEST CROW143776 <br />e and Mailing Address <br />ME <br />ry vmnanm <br />781241 44877 i <br />Form Approved. OMB No. 201, <br />2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />3 1 c $ee) �s7-745 0 019 51) 3 9 ,� � <br />eneralors Site Address (if different than mailing address) <br />LODI CHROXE <br />316 H, XAIH STREET <br />Jim ..• .r..... r-rr... ' <br />GeneratolBnEA 95248 12941169-d LORI C 95240(299)368-4691 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />21st CEl9`I'IJRY EMT <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />[Fa <br />Designaed Facility Name and Site Address U.S. EPA ID Number <br />21st Century EXI <br />2095 Newlands Dr. Bast <br />lif�sphone: Fernley, NV 89488 (775) 575-2768 WM980895338 <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br />HM and Packing Group (if any)) 13. Waste Codes <br />No. Type Quantity W"Vol. <br />1. T�3•y <br />2' MASTS CORROSIVE LIQUID, ACIDIC, INORGANIC, H.O.S. (SULFURIC ACI , D882 792 I D807 <br />R CHROXIUX) 8 UN3264 PGII RQ(0092) ERG(154) 31 TQ / Cn G <br />14* <br />WASTE CORROSIVE LIQUID, ACIDIC, INORGANIC, N,O.S. (CHROMIC ACID) C� 9002 723 D007 <br />8 U13261-PGII RQ(D082) ERG(154) TP G <br />1 13 <br />14 <br />r 6-1:91 <br />14. Special Handling Instructions and Additional Information <br />�1-}-s6416 ff- *H3 r ;.,83 (2) 367915-00 - ACID COPPER (3) 367915-00 - SPENT C.HROXIC BATE (4j 3667H9„ <br />16. 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 />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. if export shtpment and I am the Primary <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 26Z27(a) (if I am a large quantity gen or (b) (if i am a small quantity generator) is We. <br />Gf Pitor'slOfferces PrintedfTyped Name Sig ature Month Day Year <br />kC- ri',`-1 sn . le) `7 <br />LJ Import to U.S. LJ Export from U.B. Port of entrylexit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. TransporterAcknowledgment of Receipt of Materials <br />QTransporter 2 PrinledlTyped Name Signature <br />Ix <br />18. Discrepancy <br />18a. Discrepancy Indication Space 0 Quantity ❑ Type ❑ Residue <br />Manifest Refe <br />18b. Alternate Facility (or Generator) <br />J <br />W 18c. Signature of Alternate Facility (or Generator) <br />Q <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />to 1. <br />0 <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a <br />Printed/Typed Name Signature 1 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNA—= FACIt <br />❑ Padial Rejection <br />4. <br />451- 1 CD <br />Month Day <br />❑ Full Rsjectlan <br />Month Day Year <br />i'LC: v <br />10516 % I0�' <br />TO DESTMATI0JN STATE (IF AE{aUERF-D) ! .. <br />