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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 4.Manifest Tracking Number WASTE MANIFEST CAL 0 0 0 0 9 5 9 9 6 1 (800)424-9300 015481678 JJ K 5 G erators a and Mailing Address Generator's Site Address(if different than mailing address) ty,otS anteca City of Manteca 1001 West Center Street Manteca,CA 95337 1077 Milo Candini Drive,Manteca,CA 95337 (209)456-8415 Attn: Greg Showerman Generetors Phone: 6.Transporter 1 Company Name ♦ U.S.EPA IDNumber t1ZOW 7-g2 7.Transporter Company Name 7/Ar U. .EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Buttorrivillow Landfill 2500 West Lokem Road,Buttorrwillow,CA 93206 (661) 762-6200 CAD980675276 Facility's Phone: ga 911 U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(d any)) No. Type Ouancy Wt Nol. 1 611 K NA3077,Hazardous Waste,Solid,N.O.S.,(Lead),9,PG 111 001 D T 18 y Z 2. W 3, 4. 14.Special Handling Instructions and Additional Information Sail: 95-1000/0 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 Gassided,packaged, marked and labeledlpiocerded,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 mmis of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f 1 am a Large quantity generator)or(b)(itI am a small quantity generator)is true. Generaloesl0lferer's Pdntedrryped Name of(on beSignature Month Day Year }Islf Use City of MIrTIteCa) 16.International Shipments ❑ Port of a lexd: F ❑Import to U.S. Export from U.S. ng Transporter signature(for exports onty): Date lea ng U.S.'. a' 17.Transporter Acknowledgment of Receipt of Materials W Month Day Year Transporter 1 Printed(ryped Name Signature z Transporter dY Name Signature Doth Da ear a K H * 18.Discrepancy 10a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: I Be Alternate Facility(or Generator) U.S.EPA ID Number J U tai Facility's Phone: W 1&.Signature of Alternate Facility(er Generator) Month Day Year Q Z H19.Hazardous Waste Repoli Management Method Codes(i.e.,codes tar hazardous waste treatment,disposal,and recycling systems) O 1 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 Il PrintedfTyped Name Signature Month Day Year A � L EPAForm 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)