Laserfiche WebLink
ease print or type. (Form designed for use on elite (12 -pitch) typewriter. <br />7 793581 59810 <br />T <br />i <br />1. Generator ID Number <br />UNIFORM HAZARDOUS <br />Form Approved, OMB No. 205010039 <br />2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />WASTE MANIFEST CAP000143'77b <br />( 800) 567-745, 0019527-14 J, K <br />5. Generators Name and Mailing Address <br />Generator's Site Address (if different than mailing address} <br />LODI CHROXE <br />LODI MOB <br />315 N, YAIN STREET <br />316 N. MAIN STREET <br />Generators<3aruCrA 95240 209)354-4691 <br />LORI CA 95249 2'X9)303-$691 <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />21st Cri+TI'MY ALT <br />7. 7. Transporter 2 Company Name <br />0001'64012 <br />U.S. EPA ID Number <br />e. Designated Facility Name and Site Address <br />21st Century ERT <br />U.S. EPA ID Number <br />- <br />2995 Newlands Dr, last <br />Facility's Phone: Fernley, NV 89498 (775). 575-2769 <br />i�TVD980895338 <br />ga• 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />HM and Packing Group (if any)) <br />11. Total 12, Unit <br />No. Type Quantity WLNo1 13. Waste Codes <br />B_ fl4(D997) <br />5 BFB —� <br />Z <br />2. <br />w <br />c� <br />3. <br />I ( <br />rar nanmmg Instructions and Additional Information <br />(1) 370657-00 - ERG(171) FLDOB WASTE SOLIDS <br />*Gens/Offero?s <br />RATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper <br />and labeledfplacarded, and are in all respects in proper condition for transport according to applicable Intematfonal and national governmental regulatia <br />Exporer, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />ter, <br />that the waste minimization statement identified in 40 CFR 262.27(a) (if f am a large quantity generator) or (b) QFI em a small quantity generator) is true. <br />Offerors Prin /Typed Name Signd;n hi ents <br />Import to U.S. Export from U.. Portofentry/exit <br />signature (for exports only): Date leaving U.S.: <br />UJ 17, Transporter Acknowledgment of Receipt of Materials <br />OT nsparter 1 �i ed/Typed Name/ / Signatu— <br />Qcc' <br />Tr nsporter2 Printed/Typed Name Signature <br />tz' <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ -Quantity ❑Type ❑Residue ❑ Partial Rejection <br />18b. Alternate Facility (or Generator) Manifest Reference Number.Zi U.S. EPA ID Numbs <br />v <br />FacilitysPhone: I <br />pping name, and are classified, packaged, <br />If export shipment and I am the Primary <br />LU <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 1 t 2. 3. <br />20. Designated Facility Owner or Operator. Certil cation of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Prinled/Typed N <br />Signature <br />PA Form 8700-22 (Rev. 3-05) Previous editions are o okete. o 0 _ : 0 <br />� r -1 0 - G % DESIGNATED F:AC11 <br />40,7)/v <br />Year <br />❑ Full Rejection <br />��,,MIU-'V- 10 `tt_ 10 IQ <br />TO 0ESTINATiON STATE (JE F7EWRED) _ <br />