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Q) �;�j -y zelite &A�'EAS � � �.. Please print or type.(Form designed for use12-pitch)typewriter.) , Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1,Generator ID Number 2.Page 1 of 3.Emergency e;sponse Phone 4.Manifest Tracking Number WASTE MANIFEST CAC00295901El 1 888-375-5336 0187.15740JJK 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) City of Tracy 520 N Tracy Blvd. 741 N. Central Ave Generator's Phone: Tracy, CA 95376 209-831-6300 I Tracy, CA 95376 6.Transporter 1 Company Name U.S.EPA ID Number 11 X5 tnc ICArl. 06"t) 22Fl 7.Transporter 2 Comp ny Name U.S.EPA ID Number I 8.Designated Facility Name and Site Address U.S.EPA ID Number Kettleman Hills Landfill 35251 Old Skyline Road CAT 0 0 0 6 4 6 1 1 7 Facility's Phone: Kettleman City, CA 93239 (559) 386-97,11 '' ' •. ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unill HM and Packing Group(f any)) No. Type Quantity WLNol. 13.Waste Codes W 1. 1$1 Non-RCRA Hazardous Waste,Solid -11, Cna 5 Y. H2 2. W 3. 4. 14.Special Handling Instructions and Additional Information Profile No. CA614273 Account#for ER phone#is BR31029 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 EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity generator)or(b)(if I ami a small qu tity generator)is hue. Generators/Offeroes Printedfryped Name Signature Month Day Year j 16.International Shipments ~ ElImport to U.S. Export from U.S. Pohl of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17.TransporterAcknowledgment of Receipt of Materials Transporter 1 Pdntedrryped Name Signature Month Day Year a e ,ti®.rdevr- 101510 1 ff Transporter 2 Printed/ryped Name Signa Month Day Year Fes-• I 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number V ri Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) 7 TMonth Day Year Q Z H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) � 1 2. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PdntedrryediName Signature Month Day Year � a- �n�r�e� EPA Form 8700.22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) 12846.1118