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�Z.��Qrn <br /> 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.Mand Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 0 9 5 9 9 6 1 (800)424-9300 015481720 J J K <br /> 5 Gam, tof�s� .an�QM,,ailing Address GeneratorsSite Address(ifdifferent than mailing address) <br /> 7UH1 West 'MIN Street,Manteca,CA 95337 Y77 OC,CaAini Drive,Manteca,CA 95337 <br /> (209)456-8415 Attn: Greg Showetman <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ^!D ue lci,J Cr -CA1Z0b0l o <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> BuRonwfllow Landfill <br /> 2500 West Lokern Road,Buttonwillow,CA 93206 <br /> Facilitys Phone.(661)762-6200 CAD 9 8 0 6 7 5 2 7 6 <br /> ga 9b.U.S.DOT Description(inducting Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group if any)) No. Type Quantity Wt/vol. <br /> 1. 611 <br /> MC <br /> NON-RCRA Hazardous Waste, Solids,(Lead) 00 1 D T 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,packaged, <br /> marked and Iabeledlplacarded,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 cemfy that the waste minimization statement identified in 40 CFR 262.27(a)(t I am a large quantity generator)or(b)(til am a small quanty generator)is true. <br /> GeneratorstOfferors Prirtedrryped Name Signalure� Mot 8 Year <br /> (on behalf of the City of MmYeca) J 1 <br /> 16.International Shipments <br /> h ❑Import to U.S. L1 Export from U.S. Pod of lexit: <br /> Transporter signature(for exports only): Date leaving U.S.'. <br /> X 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedRypetlName., SignaNre ;/ Monty Day r <br /> QTransporter 2 Printed(typed Name Signature Month Day Y r <br /> C <br /> r <br /> I <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Parnal Rejection L1FullRejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Fadlitys Phone: <br /> W 18c Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. ' 1 2. 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 /> Pdntedtlype0 Name v l tut- 0 r// �T Signature Monts p� Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. CV'5111 DESIGNAT FACT TY O DESTINATION STATE ((IIIF REQUIRED) <br />