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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 015481712 J J K <br /> 5.Generator's Name and Mailing Address Generator's Site Address if different than mailing address) <br /> City of Manteca City of Manteca <br /> 1001 West Center Street,Manteca,CA 95337 1077 Milo Candim Drive,Manteca,CA 95337 <br /> Generators Phone:(209)456-8415 Attn:Greg Slawerman <br /> 6.Transporter1 Company Name U.S.EPA ID Number <br /> AIV61a LVA— 704Ar fill 74 7nbj <br /> 7.Transporter 2 Company Name (SAE ID Number <br /> 6.Designated Facility Name and Site Address U.S.FPA ID Number <br /> Buttomvillow Landfill <br /> 2500 West Lokern Road,Buttonwillow,CA 93206 <br /> Facllitys Phone:(661)762-6200 CAD980675276 <br /> gra 9b.U.S.DOT Description(incising Proper Shipping Name,Hazard Gass,ID Number, 10.Comainem 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WLIV.1. <br /> d' <br /> 1. <br /> O <br /> ix NON-RCRA Hawdous Waste, Solids,(Lead) 0 0 1 D T 19 Y 611 <br /> z 2. <br /> w <br /> c9 <br /> 3. <br /> 4. <br /> 14.Special Handling InsWctlors 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,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulators.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the teems of the attached EPA Acknowledgment 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)(AI am a small quan' nerator)is We. <br /> Generatoesl0lfemrs Pdntedfryped Name Signature Month Day Year <br /> (anbel®lfoftMCStyofMmtaa) � 3 g 1 <br /> —11 16.International Shipments <br /> F ❑Import to U.S. El Export from U.S. Port ofbymidt <br /> Transporter signature(for exports only): Date lea U.S.: <br /> w 17.Transporter Acknoviedgment of Receipt of Materials <br /> Transporter 1 Priptelli NameSigna a Day Year <br /> O <br /> M <br /> Transporter 2 PrIldedrTyped Name ura Month Day Year <br /> K <br /> F <br /> 16.Discrepancy <br /> 1 Ba.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Parbal Rejection ❑Full Rej.dion <br /> Manifest Reference Number. <br /> F 10b.Alternate Facility(or Generator) U.S.EPA 10 Number <br /> J <br /> U <br /> u Facility's Phone'. <br /> w 16c.Signature of Alternate Facility(or Generator) Month Day Vear <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 `,1 Z 3. 4. <br /> 20.Designated Fatality Ower or Operator:Certificatdn of receipt of hazardous materials covered by the manliest except as noted in Item 1 B <br /> PrintedRyped Name Q I V1 t yT Signabtre Month Dai <br /> 03 Gtr Y <br /> 'G <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED ACILITJTO hESTINATION STATE (IF REQUIRED) <br />