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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 14.Manifest TrackingNumber WASTE MANIFEST CAL 0 0 0 0 9 5 9 9 6 1 (800)424-9300 015 4 816 6 6 JJ K 5 GggFgqtp]e a Mailing Address Gg�q�,ra,& to AAdddrreesss(if different than mailing address) t001'�y�er Street,Manteca,CA 95337 7U l o Canadim Drive,Manteca CA 95337 (209)456-8415 Attn:Greg Showeanan ' Generators Phone: 6.Transporter Company NameU.S.EPA ID Number O b--e�rr V () 7.Transporter 2 Company me U.S.EPA ID Number 8. led Fa iNNNaatpeand, Mdmss U.S.EPA ID Number 2500 West oLolk eern$p'Rooad,Buttomvillow,CA 93206 (661)762-6200 CAD980675276 Faalitys Phone: 9a 9b.U.S.DOT Description(including Proper Shipping Name,Harem Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wit.NoI. 1 1611 D008 NA3077,Hazardous Waste, Solid,N.O.S.,(Lead),9,PG III 0 0 1 D T 18 Z z 2. 3. 4. 14.Special Handling Instructions and AddNonal Information Sal: 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'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, marked and labeledlpiacarded,and are in all respects in proper condition for tmnspon according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I candy that the contents of this consignment conform to the terms of the attached EPAAduwwledgment of Consent. I petrify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(dl am a small quantity generator)is true. GeneratofslOReroes Printedfiyped Name Signature Month Day Year (on behalf of the city of Mattlaca) LL 3 1 Q IQL 16.Intematlonal Shipments ❑Import to U.S. ❑Export from U.S. Pon of a lexit.. iDate leavi g U.S.: Transporter signature(for exports only): C17.Transporter Acknowledgment of Receipt of Materials w Month Day Year K Transporter; tecl Iypeoflame M50Signature O r y Month Day Year ffffI Z Transporter2 Printed(Typed Name V Signature Q K 18,Discrepancy 1 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Faality(or Generator) US.EPA ID Number J U LL Faolitys Phone: w 18c.Signature of Alternate Facility(w Generator) Mon Day Year Q Z 19.Hazardous Waste Report Management Method Cotler(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) � 1 j✓ '� � 2. 3, 4. 20.Designated Facility Owner tor:Certifcadon of receipt of haze materials covered by the manifest except as noted in Item 1 Be 1 Pnnted/Typed Name � Si naN Mon QayC a EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)