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3Z <br /> Please print or type.(Form designed for use on elite(12-pitch)typewntec) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID 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 015481648 JJ K <br /> 5.Gengratorsameand Mailing Address Generators Site Address(f different than mailing address) <br /> Ci of Manteca <br /> 1 Cr Street,Manteca,CA 95337 1077 Milo Candini Drive,Manteca,CA 95337 <br /> (209)456-8415 Attn: Greg Showerman <br /> Generators Phone: <br /> 6.Transpo ame'_ /��/ U. PA umber( J <br /> V, V L <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Des nateFacility Site Address U.S.EPA ID Number <br /> ==ow <br /> 2500 West Lokern Road,Buttonwillow,CA 93206 <br /> Fadlihfs Phone:(661)762 -6200 CAD980675276 <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(if any)) No, Type Quantity Wt Nal. <br /> 1. 6 1 1 D008 <br /> NA3077,Hazardous Waste,Slid,N.O.S.,(Lead),9,PG III 0 0 1 D T 18 y <br /> z 2. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions;and A ldbonal Information <br /> $oil: 95-100% Clean Harbors Profile Number: C H 13 12 3 12 B <br /> Vegetation:0-5% Wear appropriate Personal Protective Equipment as necessary <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations.If export shipment and I am the Primary <br /> Exporler,I certify 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(a)(K I am a large quantity generator)or(b)(if I am a small qq�antv generator)is true. <br /> GeneratorslOfemrs Pnntedrfyped NameSignature Month Day Year <br /> (on behalf of the City of Manteca) / \J -5 - 3 11 1 <br /> 16.International Shipments <br /> F El import to U.S. El Export from U.S. rtof ntrylexif. <br /> Transporter sign re(for exports only): D e lea ing U.S.: <br /> K 17.Tra iter edgment of Receipt of Materials <br /> Ulu <br /> P- T po 1 tsd[T Name Signa re Month Day ear <br /> O17a <br /> QTransporter2Pmrsecifiy Name Signature th Day Year <br /> C <br /> H <br /> I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type 1:1Residue ❑Partal Rejecdon ❑Full Rejection <br /> Manliest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> W 18c.Signature of Altemate Facilhy(or Genemtor) Month Day Year <br /> Q <br /> 2 <br /> S2 19.Hazardous WasteReportManagement Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> in r 1 I ✓Z 2. 3. 4. <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> I <br /> Pnntedrf d Name x Signature Month Day Year <br /> Y1 � , 1 n <br /> EPA Form 8700-22(Rev.3.05) Previous editions are otiolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />