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.Manifest Tracking Number WASTE MANIFEST C A L 0 0 0 0 9 5 9 9 6 I (800)424-9300 015481647 JJK_ 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.Transporter1 mpan�plame U.S.EPA IDD Number 7.Transporter 2 Compo 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 C A D 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)) 13.Waste Codes No. Type Quantity Wt.Nol. 1. 0 6 1 1 D008 NA3077,Hazardous Waste, Solid,N.O.S.,(Lead),9, PG III 00 1 D T 18 Y z 2. w C7 3. 4. 14.Special Handling Instructions and Additional Information Sail: 95-100% Clean Harbors Profile Number: C H 13 12 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 quantity g rator)is true. Generator's/Offerors Printed/Typed Name Signature rt Month Day Year (on behalf of the City of Maraca) /Jv\ � `QV ' � 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/xit: z Transporter signature(for exports only): -- - Date leaving .S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed ped Name O Signal Month Day Y, r ZCL 3 r 1 Transporter 2 Printed yped Name Sign r i Month Day ear H f 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Re 1 ❑Full Rejection 18b.Alternate Facility(or Generator) Manifest Reference Number: J U.S.EPA ID Number U � Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Q Month Day Year Z Cn 7 1 1 — 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) w 1 14 132 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 Printed/Type am�(� ! Signatu f 1t �/ c)V' Month Day Year EPA Form 8700-22(Rev.3_-05) Previous editions are obsolete. I 111 DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)