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, ,,. %� r� 798 ; <br />Please print or type. (Farm designed for use on elite (12 -pitch) typewriter. ! � �' <br />UNIFORM HAZARDOUS 1. Generator ID Nr 2. Page 1 of 3. Emergency Response <br />WASTE MANIFEST (:'A R000148776 1 800 5 <br />5. Generator's Name and Mailing Address Generator's Site Address (i <br />I <br />66107 <br />Form Approved. OMB No. 2050-0039 <br />4. Manifest Tracking Number i <br />4.5 003382914 JJK <br />than mailing address) <br />LORI CH8014S LODI CHRO11E <br />316 B. MAIN STREET 316 N. MAIN STREET <br />Generato n ElAn 89 6 - 691 LODI CA 95240 (2090 8- <br />6. Transporter 1 Company Name <br />'21st Y M <br />7. Transporter 2 Company Name <br />B. Designated Facility Name and Site Address <br />21st Century HNI <br />2895 NevIands Dr. East <br />Facility's Phone: Fernley,U 89488 775 575-2768' <br />ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers <br />HM and Packing Group (if any)) , No. Type <br />4341. HAZARDOUS MASTS, SOLID, N-03- (CADNIDfl,CHROXIUX,LEM) 9 NA3877 <br />R PGIIT RQ{D888) CM <br />Z 2. <br />ru <br />co <br />4. <br />U:S. EPA ID Number <br />11. Total 12. Unit 13. Wasle.Codes <br />Quantity W;Jvol. . <br />D886 D887 0888 <br />.-. Y <br />(1) 124978-88 - ERG(171) NST DHC%, TANIS 8 CI <br />I�'P 1 <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 />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemallonaland 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 EPAAcknowledgment of Consent <br />I certify that the waste minimization statement identified in 40 CFR 26227(a) (if I am a large quantity generator) or (b) lift am a small quantity generator) is true. <br />Gens106eror's Pdnted/Typed Name Sig a <br />Month <br />Da } <br />G <br />d <br />—r 16.Intemalional Vents <br />p- 11Importto U.S. ❑ Export from U:S. Port of entry/exit <br />= Transporter signature (for exports only): Date leaving U.S.: <br />LU 17. TransporterAcknowledgmentofReceipt ofMaterials <br />E4Transporter 1 Pri. d/Typed Name Si na . <br />9 <br />Month <br />Day Yr <br />Q. <br />(� <br />V <br />orter 2 PrintedlTyped Name Signahrre <br />Month <br />Day YE <br />W <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑Partial Rejection <br />❑Full <br />Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. 2. 3. 4. <br />_ �i 1 `-% 1 <br />20. Designated Facility Owner or Operator. Cerdfi lion of receipt of hazardous materials covered by the manifest'"t as noted in Item 18a <br />Printed/Typed Name ..--_ ZSIAue <br />, <br />Z.^—Z <br />Form 8700-22 (Rev 3-05) P-4- d't b I t <br />ws e <br />r woi tons are o so a e. DESIGNATED FACILITYTO DESTINATION STATE t1F t Er=0 i nEI)l <br />