Laserfiche WebLink
Please print or type.(Form designed for use on elRe(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 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 015481659 JJ K <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> City of Manteca City of Manteca <br /> 1001 West Center Street,Manteca,CA 95337 1077 Milo C-andind Drive,Manteca,CA 95337 <br /> Generators Phone:(209)456-8415 Attn:Greg Showerman <br /> 6,Transporter lCmpany Name Wpm �r �S. a (—U.S.EPA IDNumber <br /> , �-3 <br /> 7,Transporter 2 Company Name 1 U..S.xEPA IDD Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> BllGormillOw Landfill <br /> 2500 West Lokem Road,Buttonwillow,CA 93206 <br /> Facility's Phone:(661)762-6200 CAD 9 8 0 6 7 5 2 7 6 <br /> gra 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.1w. <br /> 1. 61 1 D008 <br /> C <br /> O <br /> NA3077,Hazardous Waste, Solid,N.O.S.,(Lead),9,PG III 00 1 DT 18 y <br /> Z 2. <br /> w <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> Soil: 95-100% Clean Harbors Profile Number: C H 13 12 3 12 B <br /> Vegetation 0-5% Wear appropriate Personal Protective Equipanert as necessary <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that 9%contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged <br /> marked and Iabeled/plat a ted,and are in all respects in proper condition for transport according to applicable international and national governmental regulators.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br /> I minty that the waste minimization statement identified in 40 CFR 262.27(a)(a I am a large quantity generator)or(b)(If I am a small quantity generator)is hue. <br /> GeneratorsrOlferoes PdntedrTyped Name Signature Month Day Year <br /> (onbahalfofthe CityofMakfnca) 3 2 1 <br /> J 16.International Shipments <br /> p_ 1-1Import to U.S. Export from U.S. of entrylexit: <br /> Transporter signature(for exports only): D to leaving U.S.: <br /> U.1 <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> OTran r 11 Pdn Namy __ Signature �BBj <br /> QTransporter Pdnted(ryped Nam Signature Month Day Year <br /> C <br /> H <br /> ♦ 18.Disaepancy <br /> Its.Discrepancy Indication Space EJ Oaanbty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Faddy's Phone: <br /> W 18c.Signature ofNtemate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> H19.Hazantous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 Z 3. 4. <br /> >3Z <br /> rag.Designated Facility Owren or Operator Certification of receipt of heranbus materials covered by the man'rfest except az noted in Item 18a <br /> Printed/Typed Name Sgnanum Month Day Year <br /> rC. <br /> EPAFom8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />