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Form Approved.OMB No.2050-0039 <br /> please print or".(Form designed for use on elite(12-pitch)typewriter.) 4. n'rfesl Tracking Nuer <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency <br /> ( 3 Response P <br /> hone <br /> UNIFORM HAZARDOUS CAL 0 0 O:0 9 5 9 9 6 k 7 016 4 81683 J>�K <br /> WASTE MANIFEST <br /> Generators Siie Address('rfn ail ng address) <br /> ------------ <br /> 5.Generator's Name and Mailing Address NY of Mard eca. <br /> City Of Mariam° <br /> 1077 Milo Cance Drive, aftWA,CA 95337 <br /> 1001 West Center Manteca.CA 95337 <br /> Generator's Pbone:(209)4564415 AW-Qeg Mwwemm EPA ID Number <br /> 6.Transporter 1 Company Name <br /> U. ,EPA ID Number <br /> 7.Tran rter 2 mpany Name <br /> U. .EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> $� V Lam• <br /> 2500 West Loketn R0413uttonwillow,CA 93206 CAD 9 8 0 6 7 5 2 7 6 <br /> Facility's Phone:'661)762-6200 <br /> 10.Containers I 1 .Total 12.Unit 13,Waste Codes <br /> ya 9b.U.S.DOT Description(induding Proper Shipping Name,Hazard Class,l4 Number, No Tye uantity Wt.lVOI. <br /> HM and Packing Group(�t any)) <br /> 611 <br /> L <br /> CK Y <br /> NON-RCRA HaMdDus Waste,Sohds,G94 0 0 1 D T 18 <br /> 2. <br /> W <br /> C7 <br /> I <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> Soil: 95-1000/9 Clean Harbors Profile Number: C H 13 12 3 0 7 B <br /> Vtgetaation: 0-5% Wear 1 opfiate.Personal Protective Egtripment.as necessary I <br /> 15. GENERATOR'S10FFEROR'SCERTIFICATION: Thereby declare that the contents of this consignment are fully and accurately described abo b the proper shipping name,and are classified,packaged: <br /> marked and lahekedlplacarded,and are in all respects in proper condition for transport according to applicable international and national govern n 1 regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms ofthe attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity gee tor)is true. Month Day Year <br /> GerusratdrslDiferors PrintedlTyped Nama Signature <br /> ((rl offt Ctt)r 0fM ) �.� 3 I ! <br /> 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of an 'exit: <br /> F— Date teavin U.S.: <br /> a Transporter signature(for exports only): <br /> W 17.Transporter Acknowledgment of Receipt of MaterialsMonth Day Year <br /> re Transporter 1 PrintedfTyped NameSignature <br /> O j/ <br /> Liz- <br /> rL th Day Year <br /> Transporter 2 P(injjqKName Signature <br /> i <br /> LX <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Residue Partial Rejection Full Rejection <br /> P Cr' � ❑ Quantity ❑Type <br /> Manifest Reference Number. <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> 3 <br /> Ci <br /> Facility's Phone: Month Day Year <br /> 18c.Signature of Ntemate Facility(or Generator) <br /> Qi <br /> Z <br /> 19.Hazardous W to Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 55 4. <br /> G 1. i� 2' 3i <br /> 20.Designated Facility Own r.Certification of receipt of hazardous at ' Is cowered by the manifest except as noted in Item 18a <br /> Printed/Typed NaSignature <br /> Nam <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. OM� DESIGNATED FACILITYY O DESTINATION STATE (IF REQUIRED) <br /> i <br />