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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator fD Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 0 9 5 9 9 6 1 (800)424-9300 015481646 JJ K <br /> 5.GMan Mailing Address Generators Site Address(if different than mailing address) <br /> 1 Street,Miludwa,CA 95337 WM&MMi ti Drive,Manteca,CA 95337 <br /> (209)456-8415 All Greg ShDwe®an <br /> Generators Phone: <br /> B.Transporter l Company Name �, U AID Number <br /> T G R ee s . re 000 X 73 F17a2. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.ammmum&iQMdHlUkddmw U.S.EPA ID Number <br /> 2500 West Lokern Road,Buttomvillow,CA 93206 <br /> (661)762-6200 CAD980675276 <br /> Facility's Phone: <br /> 9a. 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(l any)) <br /> No. Type Quantity Wl.Nol. <br /> 0 6 11 I D008 � <br /> NA3077,Hazardous Waste, Solid,N.O.S.,(Lead),9,PG III 0 0 1 D T 18 Y <br /> W <br /> 2 2. <br /> W <br /> C7 i <br /> 3. <br /> i <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> Soil: 95-1000/0 Clean Harbors Profile Number:C H 13 12 3 12 B <br /> Vegetation 0-5% Wear appropriate Personal Protective Equipment as necessary 3S <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 0 applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cart that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)if I am a small quantity ge or)Is two. <br /> GeneatorslOBerots PnntedfTyped Name (onbeSignature r( Month Day Year <br /> halfoftheCityofManteca) 3 1 ' <br /> rJ 16.International Shipments <br /> i ❑Import to U.S. ❑Export from U.S. Porto text: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> � Transported P nletl/Ty Na e <br /> 0 Signature Month Day Year <br /> /t7 I / <br /> Z Transporter 2 Pnnted/Typed Name <br /> Signature 9 Month Day Year <br /> H <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Ouanfiry ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br /> Manliest Reference Number: <br /> 186.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facillt/s Phone: <br /> w 18c.Signature of Allemate Facility,(or Generator) <br /> Q Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1 2. 3. <br /> 4. <br /> 1 ISZ <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the mani except as noted in Item Ise <br /> Printed?yped Name Signature Month Day Vear <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />