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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1•Gene I ator lD NIII bor 2.Page 1 of 3.Emergency Response PhoneForm 4.Manifest Tracking Approved.OMB Na.2050-0039 <br /> WASTE MANIFEST CAL 0 0 0 0 9 5 9 9 6 1 (800)424-93000154-81684 <br /> mber <br /> 5.Ge8e�lors an Mailing Address 015 4 816 8 4 JJ K <br /> [j Stre Geea�nerator s'to Address(If different than mailing add <br /> Generator's Phone: (209)456-8415 Attn: Greg ShOWerman ress) <br /> �,Manteca,CA 95337 I"� an�ini Drive,Manteca,CA 95337 <br /> 6,Transporter I Company Name <br /> 5 U.S.EPA ID Number <br /> 7.Transporter 2 Company Nam ,012 F Q <br /> Q� g U.S.EPA fD Number <br /> B.tsIiiCOed Fa i i0w 1,8iltg Address <br /> 1 U.S.EPA ID Numher <br /> 2500 West Lokern Road,Bultonvvillow,CA 93206 <br /> (561)762-6200 <br /> Facility's Phone: CAD 9 8 0 6 7 5 2 7 6 <br /> 9a. 9b.U.S.DOT Description(includirg Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(f any)) 10.Containers 11.Total 12,Unit <br /> 1. No. Type Quantity Wt. . 13.Waste Codes <br /> O <br /> 611 <br /> NON-RCRA Hazardous Waste, maids,(Lead) _ <br /> Z 2. <br /> LU <br /> 0 0 1 D T 18 Y ._ <br /> i <br /> c� <br /> 3. <br /> t <br /> 4. <br /> . � I <br /> 14.Special Handling Instructions and Additional Information <br /> Soil: 95-100% Clean Harbors Profile Number.: C H 13 12 3 0 713 <br /> A. <br /> Vegetation:0-5°/n Wear appropriate Personal protective E <br /> Quiprnent as necessary <br /> 15. GENERATOR'510FFEROR'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, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable Intemationaiand nafional governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiodgment of Consent. <br /> I oertify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or I(if I am a smalluanti <br /> Generator'slOfferor's PrintedlTyped Name q h+9 tar)is true. <br /> (°n behalf of the City of Manteca) <br /> Signa re Month Day Year <br /> 16.International Shipments CrL fJ <br /> ~ ❑Import to U.S. 4. <br /> Transporter signature(for exports only): ❑Export from U.S. Port of en Iexit <br /> Uj <br /> 17.Transporter Acknowledgment of Receipt of Materials Date leavi U.S.: <br /> Transporter 1 Pdnted/Typed Name <br /> C) Signature Month Day <br /> � .� <br /> Q TYear <br /> ransporter 2 PrintedlTyped Name <br /> Signature <br /> F— Month Day Year <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> IZ 18b.Alternate Facility(or Generator} Man fest Reference Number: <br /> Z5 U.S.EPA ID Number <br /> Z5 <br /> Facility's Phone: <br /> W 18c.Signature ofAItornate Facility(or Generator) <br /> Z Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for Inez <br /> LU 1 us waste treatment,disposal,and recycling systems) <br /> J 3 Z 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pdnted/Typed Name Signature <br /> � Month Day Year <br /> J d <br /> :PA Farm 8700-22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />