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Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 0 9 5 9 9 6 1 (800)424-9300 015481695 J J K <br /> 5.Generators Name and Mailing Address Generators Site Address('d different than mailing address) <br /> City of Manteca City of Manteca <br /> 1001 West Center Street,Marteca,CA 95337 1077 Milo Candini Drive,Manteca,CA 95337 <br /> Generators Phonre:(209)456-8415 Attn: Greg Showerman <br /> 6.Transporter 1 Company Name U.S. PAID Number <br /> S o N 1J6 L <br /> 7.Transporter 2 Company Name V U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address U.S.EPA ID Number <br /> Buttormillow Landfill <br /> 2500 West Lokem Road,Buttonwillow,CA 93206 <br /> Facll sPh":(661)762-6200 CAD980675276 <br /> got 911a.U.S.DOT Description(including Proper Shipping Name,Hai Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Padang GMUP(i anyll No. Type Quantity Wt.Nol. <br /> 1. 611 <br /> O <br /> NON-RCRA Hazardous Waste, Solids, (Lead) 00 1 DT 18 Y <br /> z 2. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> Soil: 95-100% Clean Harbors Profile Number: C H 13 12 3 0 7 B <br /> Vegetation 0-5% Wear appropriate Personal Protective Equipment as necessary <br /> 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,padreged, <br /> marked and labeledlplanmed,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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(a I am a large quantity genemtor)or(b)it am a small quan6 nerator)is true. <br /> GenemturslOffarors Pdntedrryped NameSignature Month Day Year <br /> (onbehalf of the City of M�teca) <br /> 16.International Shipments <br /> F El import to U.S. 0 Export from U.S. Pon ofhylexiF. <br /> Transporter signature(for exports only): Date lea ng D.S.: <br /> W 17.TmnsporterAcknowledgment of Receipt of Materials <br /> Z Signaur •r` Month Day <br /> Year <br /> Print <br /> a _ Cl /l C <br /> Transporter PnntWme <br /> Signature Month Day Year <br /> K <br /> F <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residueje ❑ I <br /> ❑Partial Re coon Full Rejection <br /> Manifest Reference Number: <br /> 186.Aaemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facinlys Phone: <br /> w 18c.Signature ofAlternate Facility(or Cenemtor) Month Day Year <br /> a <br /> z <br /> N <br /> 19.Hazardous Waste Report Management Method Codes 9.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 � -L 2. 3. 4. <br /> 20.Designated F-acilJlity Omer or operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PnntedRyped Name1 Signature Month Day Year <br /> Auu l 11 o3 loh <br /> EPA Forth 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FA ILITY ItPISTINATION STATE (IF REQUIRED) <br />