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Please print or type. (Form designed for use on elite (12 -pitch) typewr UNIFORM HAZADO ""'US 1.1. Generator ID Number WASTE MANIFEST 5. Generators Name and Mailing Address LODI CHBOM$ 316 N. MAIN STREET 6. Designated Facility Name and Site Address 21st Century Environmental Manageaent of Nevada, LLC 2095 Newlands Dr. East Facllitys Phone: Fernley, NV 8908 775 575-2760 ga, 9b. U.S. DOT Descript on (Including Proper Shipping Name, Hazard Class, ID Number, HM and Packing Group (if any)) 1. o NON BCNA HAZARDOUS WASTE SOLID z 2. LU 4. LODI CH&DMS 316 N. MAIN STIRET 14429 Y Form Approved, OME No. 2050.0039 Manifest Tracking Number .005522049 JJK ling address) ID Number. ... ,. . 10. Containers 11. Total 12. Unit No, TYPH Quantity Wt.N01. 13. Waste Codes C71 1 14. 6peclal Handling instructions and Additional Information (i J.,396636-88tx- CONCRETE: AND SOIL: WI 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 labelediplacarded, 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 EPAAcknowiedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Gene rator•slOfferors Pdnied/iyped Name Signatu Month Day flDour, by k 5 o1v 1C j 16. International Shipments Z ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: 17. TransporterAcknowledgment of Receipt of Materials LU Transporter 1 Pdnted(Typed Name Sign ur Month Day Yi zQ Transporter 2 Printefffy-pecrName Signature Month Day Yi F- 18. Discrepancy 18a. Discrepancy Indication Space❑ Residue ❑ Partial Rejection Quantity El Type j ❑Full Rejection Manifest Reference Number. 181b. Alternate Facility (or Generator) U.S. EPA ID Number U LL Facility's P_hone:--_-___-__-------------_-_-- _--- ---_—_-- 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) UJ 1 • � � 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except qliakd in Item 18a Pdnled yped Nave .., Signature Month Day Yea Z,) —7 —Ta—lyn 'A, EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. - 01-14-09A08 23 RCUD DESIGNATED FAC �LY TO DESTINATION STATE (IF REQUIRED)