FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Man'dest Tracking Number WASTE MANIFEST CAL 0 0 0 0 9 5 9 9 6 1 (800)424-9300 015481623 J J K 5.Generators Name and Mailing Address Generators Site Address(d different than mailing address) City of Manteca City of Manteca 1001 West Center Street,Manteca,CA 95337 1077 Milo Candim Drive,Manteca,CA 95337 Generators Phone: 209 456-8415 Attir Greg Showerman 6.Transposer mpany� U.S.EPA ID Number /� G d Z Transporter Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Buttornwnllow Landfill 2500 West Lokern Road,Buttolmllow,CA 93206 Facil ty's Phone:(661)762-6200 CAD 9 8 0 6 7 5 2 7 6 qa 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 1I.Total 12.Unit 13.Waste Codes HM and Packing Group(If ani No, Type Quantity Wt.Nol. 6 1 1 D008 NA3077,Hazardous Waste,Solid,N.O.S.,(Lead),9,PG III 00 1 D T 19 Z' W 2 t7 I 3. 4. i 14.Special Handling Instructions and Additional Information Soil: 95-1000/6 Clean Harbors Profile Number: C H 13 12 3 12 B Vegetation 0-5% Wear appIrTnate Personal Protective Eclinpratent as necessary 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 Iabeledlplacarded,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 EPA Acknowledgment of Consent. I party that the waste minimizabon statement identified in 40 CFR 262.27(a)bf I am a large quantity generator)or(b)(if I am a small quantity generator)is We. GenerstorsrORerors Printed/Typed Name (onbeSignature Month Day Year llalt'of Qty S I 16.International Shipments ❑Import to U.S. ❑Export from U.S. Pon ntrylextt: Transporter signature(for exports only): Date le ving U.S. W 1TTrd4 our'nt ped Nanowledgmenlof Racei fMatenals OTran o r 1 me Signa Month Day Year a n Q Train s ner2 Print ed Name Signature Month Day C elar F 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type y El Residue ❑PadWl Rejection El Full Rejection Manifest Reference Number: 181b.Alternate Facility(or Generator) U.S.EPA ID Number J U I Facility'SPhone'. yOj 1Be.Signature of Alternate Facility(o(Generator) Month Day Year Q Z H19.Hazardous Waste Report Management Method Codes ike.,codes for hazardous waste treatment,disposal,and recycling systems) W 1 ' 2. 3. 4. O 20.Designated Facility Owner or Operator:Certification of receipt of hmrdous materials covered by the manifest except as noted in Item 18a 111 Pdnled(Typed Name Signature Month Day Year 0 1 I's- 14g— EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)