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Please print or We. (Form designed for use on elite (12 -Ditch) tvGewriterJ IN l 904385 <br />,�.. ,. 16203 <br />Form Approved. OMB No. 2050.0039 j <br />Manifest Tracking Number <br />LHA Hcrm 8100-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACIL�y TO DESTINATION STATE (IF REQUIRED) _ <br />I <br />UNIFORM HAZARDOUS <br />1. Generator ID Number 2. Page 1 of <br />3. Emergency Response Phone 4. <br />WASTE MANIFEST <br />CMOW143776 1 <br />877 577-266 t0 0 5 5 2 2114 JJ K <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />LODI CHBONE LODI CHROME <br />316 H. RAIN STREET 316 N. ![AIN STREET i <br />Generet,W14, A 95240 (219)368-4691 LODI CA 95240 209 368-4691 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />21st CE3!AMY ENVIRONMENTAL MANAGEMU OF NEVADA, LLC CAROW164012 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facillty Name and Site Address U.S. EPA ID Number <br />21st Century Enviromental ]lanagetent of Nevada, LLC <br />2195 Newlands Dr. East <br />Facility's Phone: Fernley, NP 89408 (775) 575-2760 WD980895338 : <br />93 <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11, Total <br />12. Unit <br />13. Waste Codes <br />No, <br />-yae <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wf.Nol. <br />1. <br />181 <br />`a3 <br />CF <br />3 <br />Y ., <br />w <br />2. <br />rz <br />c� <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />(1) 396636-00 - CONCRETE AND.SOIL HI <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this xnsignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeledlplacarded, 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 EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 26'2.27(a) (if I am a large quantity generator) or ) (if I am a small qu y generator) is true. <br />Generator'slOfferor's PrinledlTyped Name Signator Month Day Year <br />-1j 0 v G- 1-)4 9 S-5 moi✓ Iz o <br />F- <br />16. International Shipments <br />❑Importfou,S. Export from U.S. Port ofentrylexll: <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />Trans oner I P- ntefyped Name J ( ^ Slg�ure Month Day Year <br />z <br />Q <br />Transporter 2 Printed7Typed Name gnature Month Day Year <br />ti <br />18. Discrepancy <br />18a. Discrepancy Indication Space quantity ❑ Type El Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />� <br />Facilrys.P.hone:------------------------- --- ------ <br />- -- ------------ - <br />-_ <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />F - <br />Q <br />Z <br />C2 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 1. <br />H / 4 1 <br />2. <br />3. <br />4. <br />20. <br />Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ed in Item 18a <br />Printed/Typed <br />Ll <br />Name Signature ' p /I �Mo%nth Day YAW - <br />6 E <br />e --z- Qi" I V�g W ✓ V l <br />LHA Hcrm 8100-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACIL�y TO DESTINATION STATE (IF REQUIRED) _ <br />I <br />