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886935 74843 j <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) L ,Tri Farm Approved OMB No. 2050.0039 <br />vmru RlY1 rnHGHKUVUJ .. __.._. _._.._ ..-...__. <br />WA'"MANIFEST CAROW143776 <br />_.. -,_ . -. ...-,,,,,,y,,,,,,r ,..,.,Y,,,,., (, �,�„� <br />1 877 577-2664'-5"N'§50100 <br />y i�wnunr — <br />JJK <br />5. Generator's Name and Mailing Address <br />Generator's Site Address If different than <br />mailingaddress <br />LODI. CHROXE <br />LODI CHROKE <br />316 N. KAIN STREET <br />316 N. MAIN STREET <br />Generdti:19111or9A 95240 (209)368-4691 <br />LODI CA 95240 (21900-4691 <br />S. Transporter 1 Company Name <br />U.S. EPA ID Number <br />21st CENTURYENVIROME TAI- MANArF24VNT <br />7. �nsporler 2 COMAY Name <br />U.S. EPA ID Numbe <br />8. esigna ed aciliry Na e a d Site Address <br />U.S. EPA ID Number <br />21st Century EnvlrantentaI Ninageaent of Nevada, LLC <br />2095 Newlands Dr. Bast <br />Facility's Phone: Fernley, NV 89408 (775) 575-2760 <br />NVD960895338 <br />o a gb. U.S. DOT Dasntinn findiidinn P—r Rhinnien time W—M rl— m ni„T ., .:1 <br />HM I and Packing Group (if any)) <br />•-• - 1 .. IUlal 1L. um[ <br />No. Typo Quantity WkNol. 13. Waste Codes <br />neaelf HALAom HASTE, SOLID, N.O.S. (CHRONIUH) 9 FGIII 0607 181 <br />�J R 19(0007) <br />/000 1 <br />P <br />12. NOR-RCIA HAZARDOUS WASTE SOLID 0 181 <br />30 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />(1) 393535-01 - ERG(171) CONCRETE CONTAMINATE (2) 393532-00 - FLOOR TILES CONTANINMBAR PROPER HE <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 international and 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 EPAAcknowledgme f Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator or ) (rf I am a small quan' generator) is true. <br />Ge ratolslOfferces Printed/Typed Name Signa a Month Day Year <br />>L-� — v v /' <br />16. Intemational Shipments <br />i` ❑ Import to U.S. ❑ Export from <br />Transporter signature (for exports only): <br />117. TransperterAcknowledgment of Receipt of Materials <br />Q iransponerzrnmecny e0 Name pL, <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />Quantity ❑Type <br />18b. Aitemate Facility (or Gener or) r <br />ort of entry/exit: <br />Date leaving U.S.: <br />❑ Residue <br />❑ Partial Rejection <br />U.S. EPA ID Number <br />e6 d '-2 d <br />onth Day Year <br />Q J�I ir <br />❑ Full Rejection <br />LU 1Be. Signature ofAltemate Facility (or Generator) Month Day Year <br />Q <br />z <br />LURX <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />4. <br />Designated FacilityOwner or Operator, Certfication of receipt of hazardous materials covered by the manifest except as in Item 18a <br />dnted/Typed Name �i Lam� <br />� Signature �Mpnlh Da Year <br />EPA -Form 8700.22 (Rev. 3-05) Previousdf� are obsolete. jJ� /(Ji1 <br />- . - - n r,r n DESIGNATFn FOCI' T Tn nt=CThtUATrnnr c rA r= ne oenr noern <br />