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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.Manifest Tracking Number WASTE MANIFEST C A L 0 0 0 0 9 5 9 9 6 1 (800)424-9300 015481645 JJ K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) City of Manteca City of Manteca 1001 West Center Street,Manteca,CA 95337 1077 Milo Candini Drive,Manteca,CA 95337 Generator's Phone:(209)456-8415 Attn: Greg Showerman 6.Transporter 1 Company Name U.S.EPA ID Number / r 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Buttonwillow Landfill 2500 West Lokern Road,Buttonwillow,CA 93206 Facility's Phone:(661) 762 -6200 CAD 9 8 0 6 7 5 2 7 6 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes 1. 6 1 1 D008 0 X NA3077,Hazardous Waste, Solid,N.O.S.,(Lead),9,PG III 00 1 D T 1 8 Y w M 2. UJ 3. 4. '4 Special Handling Instructions and Additional Information Soil: 95-100% Clean Harbors Profile Number: C H 1 3 1 2 3 12 B Vegetation 0 -5% Wear appropriate Personal Protective Equipment as necessary 15. GENERATOR'S/OFFEROR'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 EPA Acknowledgment 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 quan ty nerator)is true. Generators/Offeror's Printed(Typed Name Signature Month Day Year (on behalf of the City of Manteca) 3 1 l � 16.International Shipments ❑Import to U.S. ElExport from U.S. Port ofe tryg U.S.: /exit: Transporter signature(for exports only): w 17.Transporter Acknowledgment of Receipt of Materials Date leav IX Transporter 1 Printed,Ryped Name / Signature , Month Day Year 0 �'`/ Qa l /- Transpo ter 2 Printed/Typed Name Signature Month Day Year t- 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 U LL Facility's Phone: LU 18c.Signature of Altemate Facility(or Generator) Month Day Year a z 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU� 1 Hi Z i �J 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pnnted/T Name Signature Month Day Year EPA Form 870 - (Rev.3-OS) Previous editions are obsolete. DESIGNATED FACILITY TO D TINATION STATE (IF REQUIRED)