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PI63se print a type.(Form designed for use'on elite'(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> •UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4:Manifest Trael3ng Num <br /> wnsrEMANIFEST CAL000040958 1 (800)359-4555 JJK <br /> 5.Generator's Name and Mailing Address Gene ato's Site Address(d di ferent than mailing address) <br /> Stockton Unified School District Weber Tech <br /> 1944 N. EI Pinal Drive 302 W.Weber Avenue <br /> Stockton CA 95205 Stockton CA 95203 <br /> Generators Phone: 209 933 7045 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> APC Contractors, Inc. 4606 N.Bendel Avenue Fresno Ca 93722 1 CAD120804497 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Forward, Inc.Landfill <br /> 9999 Austin Road <br /> Manteca CA 95336 <br /> Facility's Phone: 209 982 4298 CAL000190080 <br /> ger 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt.NoI. <br /> c 1. RQ, ASBESTOS, 9, NA2212, PGIII (ERG 171) BA Y 151 N/A <br /> W 2 <br /> 3. <br /> 4. <br /> 14.Spedal Handling Instructions and Additional Information <br /> Project: Weber Tech (29.079) <br /> Profile: 753310 <br /> 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, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemationnal and national governmental regulations.If export shipment and 1 am the Primary <br /> Exporter,l 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)(d 1 am a large quantity generator)or(b)(di am a small quantity generator)is true. <br /> Generator'slOfferor's PdntedfFyped Name Signature. Month Day Year <br /> ❑ <br /> r I tunaf Stii <br /> Z ❑Import to U.S. Export from U.S.U.S. Port of entry/exit <br /> sporter signature.(for exports only): Date leaving U.S.: <br /> W 17.Transporter A knowledgment of Receipt of Materials <br /> Transporter 1 PrintedRyped Name a. Signature Moth Day Year <br /> O <br /> Transporter 2 PdntedlTyped Name Sign r-e Mordh Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> �. 18b.Alternate Facility(or Generator)_ U.S.FPA ID Number <br /> V <br /> L#- Facilitys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,cedes for hazardous waste treatment,disposal,and recycIN systems) <br /> LU® 1' <br /> H132 <br /> 2' <br /> 20.Designated Facility Owner or Operator Ceirlificatioh of receipt of hazardous materials covered by the manifest excepIp noted in")8a <br /> PrintedlTyped Name j r <br /> Signature Mortar DY r <br /> ' <br /> EPA 00-22(Rey.3-05) Previous edipons.are obsolete. <br /> DESIGNATED FACILITY:TO GENERATOR <br />