FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

Please print or type.(Foran designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator IO Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAL 0 0 0 0 9 5 9 9 6 I (800)424-9300 015481667 J J K 5.Generators Name and Mailing Address Generator's Site Address(d different than mailing address) City of Manteca City of Manteca 1001 West Center Street,Manteca,CA 95337 1077 Milo Candua Drive,Manteca,CA 95337 Generators Phone:(209)456-8415 Attn: Greg Showemnan 6.Transporter 1 C any Name U.S.EPA ID Number ` ,000 I 6 S 69 7.Transporter 2 Company Name U. .EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Buttonwillow Landfill 2500 West Lokern Road,Buttonwillow,CA 93206 Fath a Phone:(661)762-6200 CAD 9 8 0 6 7 5 2 7 6 as. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11,Total 12.Unit 13.Waste Codes HM and Packing Group(I any)) No. Type Quantity Wt.Nol, K 6 1 1 D008 O NA3077,Hazardous Waste,Solid,N.O.S.,(Lead),9,PG III 00 1 D T 18 Z Z 2. w CD 3. I I L _ 4. 14.Special Handling Instrudons and Additional Information Sail: 95-100% Clean Harbors Profile Number: C H 1 3 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 dassified,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 Bre Primary Exporter,I certily mal the contents of this consignment conform to the terms of the allached EPAAcknoWedgmenl of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity generator)or(b)(fl am a small quamm generator)is true. GeneratoeslOferoes PrintedName Signature Monro Day Year lryped (on behalf of rite City of Mmdeta) j 2 ) 16.International Shipments p_ ❑Import to U.S. Export from U.S. Portof ")exit Transporter signature(Nr exports only): Data leaving LLS: IW 17.Transporter Acknowledgment of Receipt of Materials Trans PnntedRyp Name Signature Monro Day Year e N ~ / 2Tlantporter 2 PrintedRyyed Name Signator Month Day Year C H 1B.Discrepancy 18a.Discrepancy Indication Space ElQuantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL periliys Phone' W 18c.Signature of Alternate Facility(or Generator) Monro Day Year Q Z H19.Hazarcloys Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) D 1' 2. 3. 4. 20.Designated Facil' or Operator:Certification of receipt asamous materials covered by the manifest except as noted in Item 18a Pnnled/Typed Na ,. Signature ,Mon Day Year 017y 7 liter/.)S EPA Form 870-22(Rev.3-05) Previous edition are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)