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�P ' JI)) ��'� f 806694 76022 Please print or type. (Form deSlQned for use on elite (12 -pitch) tVoevvriterV'L.i(-- l / �-o O ! Form Aonmvad 0MR Nn vnrn-nnAo tt'At-ormdiuu-tLtMev.a-uo) rreviuuseumonsare'uuburerFf. - - CJE5l4LajNJAJ tll 11-tAfr:l-l1 7 1U UCJ I INAI IVIS JJAI =ill 431=L,INineia) UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone Manifest Tracking Number WASTE MANIFEST 3 800) "A 5 003 74948 JJK T 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) i LODI CHROPH LODI CHROKS 315 N. KAIN SMET i 316 N, MAIN STREET Generatorlsl%SA 95242 (209)363-4691 LODI CA 95210 (2291368-4691 6. Transporter 1 Company Name U.S. EPA ID Number 21st M''TMY 1� CAR000164012 7. Transporter 2 Company Name n U.S. EPA ID Nu/m7ber 61 - 7a 8. Designated Facility Name and Site Address U.S. EPA ID Number 21st Century EXI 2095 Newlands Dr. East Fadtity'sPhone: Fernley, NV 89408 (775) 575-2762 / NfiL980395338 ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (f any)) Quantity WtNol. o X T MEMO S , 5 , I .. . (C OX .1r, , ) U ti 84(DO08) BA S % P goo 181 Z 2. NOMCBA HAZARDOUS RAVE LIQUIDGI ' TP G 13LU2 3. I 4. 14. Special Handling Instructions and Additional Information (1) 370657 00 - EB(171) FLOOR WASTE SOLIDS (2) 124987-00 - RINSE WATER 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, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 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 generata e. 's Pdnted/Typed Name Signature Month Day Year Generator's)!,?n LA5S 12 Z 10Z -j 16. international Shipments ❑ Import to U.S. Export S. Po entry/exit: z Transporter signature (for exports only): ate leaving U.S.: 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/T ed Nam Signature Month Day Year 7 ° 7 0.es s ��--� En Transporter 2 Printed/Typed Name Signature Month Day Year Z'' 18. Discrepancy 18a. Discrepancy Indcalion Space ❑ Quantity ❑Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J — - ----- — -- — nFacililysPhone: 18c. Signature of Alternate Facility (or Generator) Month Day Year 4 Z Fn -(D 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LU 1 �� 2 I J � �i 3 4. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as road in Item 188 PdnledlTyped N Signature Month Day Year tt'At-ormdiuu-tLtMev.a-uo) rreviuuseumonsare'uuburerFf. - - CJE5l4LajNJAJ tll 11-tAfr:l-l1 7 1U UCJ I INAI IVIS JJAI =ill 431=L,INineia)