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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) W l TS <br />UNIFORM HAZARDOUS I 1. Generator ID Number T. Page 1 of 3. Em( <br />WASTE MANJFEST CAR000143776 1 ( 877) 57, <br />5. Generalor's Name and Melling Address Generator's Site Address (if dif <br />LODI C111013 LODI C®ONE <br />316 N. IAIN STREET 316 A. MAIN STIRST <br />Generat,W062 95241 (219)368-4691 LODI CA 95241 219 <br />6. Transporter 1 Company Name <br />21st C ENTURY ENVIRONNE2n.AL mMGEKE ' 0F'. NEVABA-,,--L , . <br />941691 - <br />21st Century Enviroaiental Ianagevent of Nevada, LLC <br />2195 Newlands Dr. East, <br />Facility's Phone: Fernley, KV -8941a;(775) S75 -2760- <br />9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) <br />0 1' NON RCRA HABABDODS MASTS SOLID (CONCRETE AND SOIL) <br />Dela <br />L <br />Z 2. <br />rJ <br />40580 <br />proved. OMB No. 2050.0039 <br />or <br />%640.5518616 JJK <br />than mailing address) <br />U.S. EPA ID Number <br />- NVD980895338 <br />10. Containers 11. Total 12. Unit 13. Waste Codes <br />No. Type Quantity Wt .vol, <br />9181 <br />i7 ti C,p CF �� 1abCj P <br />• -• -- -- 111— - --' . ""'ua oumun5 die uusujern. nFSlr;NATFn FAC❑ A71V To DESTINATION -QTGTF /1F RF(3111Rp ) <br />14. Special Handling Instructions and Additional Information <br />(1) 396636-11 - CONCRETE AND- SOIL! 1I --BEAR PROPHR4FE ,... <br />15. GENERATOR'SIOFFEROWS 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 intemational 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 EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified In 40 CFR 262.27(a) (If I am a large quantity generator) or if I am a smati quantity ge tor) is true. <br />ene lor'slOfferor's Printed/Typed Name Signatu Month Day Year <br />1 Std <br />-u <br />F <br />16, International Shipments <br />of entry/o <br />❑ Import to U.S. ❑ Export from U.S. ort : <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />LU <br />17. Transporter Acknowledgment of Receipt of Materials <br />OTran <br />1 PrintedliypedName Si <br />Month Days Year <br />CL <br />�grn <br />Tran <br />Al <br />ed) d lmme� Sign ^ Month Dgy Yegr <br />// <br />3 33 �'C�j <br />Fza- <br />I ✓,1� Cn <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑Type ❑ Residue ❑ Partiai Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />16b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />V <br />LL <br />�adiiry's Phone,,--,--- -- -- --- ----- — - - — <br />Q <br />18c. Signature ofAltemate Facility (or Generator) Manih Day Year <br />19. Hazardous Waste Report Management Method Codes (I.e., codes for hazardous waste treatment; disposal, and recyding systems) <br />O <br />1 4. <br />.Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as Ad in Item 189 <br />Pnntedilyped Name Q�%/�� Signature <br />i <br />=n VZ..1. " <br />Month Day Year <br />Or Vito <br />Goe <br />c _ o r <br />• -• -- -- 111— - --' . ""'ua oumun5 die uusujern. nFSlr;NATFn FAC❑ A71V To DESTINATION -QTGTF /1F RF(3111Rp ) <br />