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r . i ' Please print or type. (Form designed for use on eFte (12 -pitch) typewriter.),5Y 904385 UNIFORM HAZARDOUS I 1. Generator ID Number 2. Page 1 of 3. Emergency Response one 4, Manifes WASTE MANIFEST CAR000143776 1 877 577-26610 0. 5. Generator's Name and MailingAddress Generators Site Address (if different than mailing addrE LODI CHROME LODI CHROME 316 N. MAIN STREET 316 H. MAIN STREET GeneratMPLA 45240 (209)368-4691 LODI CA 95240 (219)368-4691 E. Transporter 1 Company Name U.S. EPA ID 91945 Farm Approved. OMB No. 2050-0039 ig Number 31188 JJK 21st CENTLRY ENVIRONMENTAL NANAGEMM OF NEVADA, LLC CAROW164012 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA 0 Number 21st Century EnviranientaI Managesent of Nevada, LLC 2095 Newlands Dr. East 3. (1) 396636-00 - CONCRETE AND SOIL NIREAR PROPER PPS 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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if) am a large quantity generato (b) (if; am a small cuanli generator) Is true. GeneratcrslOfferors PrintedlTyped Narre Sig. e Month Day Year -J 16. International Shipments El Import to U.S. Expo from U.S. ort of a /exit: Z Transporter signature (for exports only): ' Date leaving U.S.: LU 17. Transporter Acknowledgment of Receipt of Malehals � Transporter 1 Printed/T ped Name , S�1,nat d _ Month Day Year r �. z/f 1,1-21 ay onth Dav Year 18a. Discrepancy Indication Space ❑ Quantity ❑ Type El Residue ❑ Parlial Reja,tlon ❑Full Rejection Manifest Reference Number: >- 18b. Altemate Facility (or Generator) U.S. EPA ID Number 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) n 1' //lJ 2. 3. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted'n Item 18a Printed[Typed Name1 Signature P, -Z -m EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACIL 4. TO DESTINATION STATE (IF REQUIRED; Fernley, NV 89408 (775) 575-2760 1 NM980895338 Facility's Phone: 9a 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 (if any)) Quantity Wt.Nol. 1 NON RCRA HAZARDOUS WASTE SOLID ,t1 X.- 181 13 CF a Lu Lu Z 2 0 3. (1) 396636-00 - CONCRETE AND SOIL NIREAR PROPER PPS 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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if) am a large quantity generato (b) (if; am a small cuanli generator) Is true. GeneratcrslOfferors PrintedlTyped Narre Sig. e Month Day Year -J 16. International Shipments El Import to U.S. Expo from U.S. ort of a /exit: Z Transporter signature (for exports only): ' Date leaving U.S.: LU 17. Transporter Acknowledgment of Receipt of Malehals � Transporter 1 Printed/T ped Name , S�1,nat d _ Month Day Year r �. z/f 1,1-21 ay onth Dav Year 18a. Discrepancy Indication Space ❑ Quantity ❑ Type El Residue ❑ Parlial Reja,tlon ❑Full Rejection Manifest Reference Number: >- 18b. Altemate Facility (or Generator) U.S. EPA ID Number 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) n 1' //lJ 2. 3. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted'n Item 18a Printed[Typed Name1 Signature P, -Z -m EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACIL 4. TO DESTINATION STATE (IF REQUIRED;