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'r <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> a <br /> UNIFORM HAZARDOUS 1.Generafor ID Number Farm Approved.OMB No.2)50-0039 <br /> CAL000095996 0 0 0 9 5 9 9 6 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> r WASTE MANIFEST 1 (800)424-9300 0 C <br /> 5.Generator's Name and Mailing Address J K <br /> City Of Manteca Generator s Site Address(if different than ailing address) <br /> City of Manteca <br /> 100 I West Center Street Manteca, CA 95337 1077 Milo Candini DriveVl <br /> Generator's Phone:(209)456-8415 Attn:(3=Showermarr anteca,CA 95337 <br /> i Transporter 1 Company Name <br /> /a p �, 0. x t1.S.EPA ID Number <br /> 7.Transporter 2 Company Name / ! �V u -s�ic �� c- Fi. CA 12-0010 <br /> iEPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> Buttonwiltow Landfill .S.EPA ID Number <br /> 2500 West Lokern Road,BuItOnwillow,CA 93206 <br /> Facility's Phone:(661) 762-6200 ' CAD 9$0 6 7 5 2 7 6 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(If any)) 10.Containers 1�.Total 12.Unit <br /> 1. No. Type (luantity Wt Nal. 13.Waste Code <br /> fY <br /> 0 611 ` <br /> a4 NON-RCRA Hazardous Waste, Solids,(Lead) __ _i------ <br /> M 2. 00 1 DT 1 Y <br /> LU <br /> c� <br /> 4. <br /> s � <br /> t <br /> i e <br /> I <br /> { <br /> 14.Special Handling Instructions and Additional Information ! <br /> Soil: 95-I00% Clean Harbors Profile Number: C H 13 12 3 0 7 B <br /> Vegetation 0-5°1° Wear appropriate Personal Protective E <br /> llidae necessary <br /> i5. GENE RATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuurrately described bed by the proper shipping name,and are classified,packag , <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Prima <br /> ry <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity <br /> Generator's/Offerors Printed/Typed Name nerator)is true. <br /> (on behalf of the City ofhjaIlftCa) Signature Month Day Y ar <br /> J 16.International Shipments u �J""�' 8 <br /> z ❑Import to U.S. ❑Export from U.S. Port of /exit: <br /> Transporter signature(for exports only): <br /> W 17.Transpo terAeknowledgment of Receipt of Materials Dale leaving U.S,; <br /> Transporter 1 PrintedlTyped N e <br /> ` ' Signature��� <br /> Month Day Y r <br /> Qa SCJ C T' <br /> porter 2 TransPrintedlTyped Name 3 <br /> Signaturo <br /> F- Month y Year <br /> 18.Discrepancy <br /> 1$a.Discrepancy indication Space <br /> ❑ Quantity ❑Type ❑Residue <br /> ❑Partial Rejection ❑Full Rei do <br /> 18b.Alternate Facility{or Generator) Man test Reference Number: <br /> U <br /> U.S.EPA ID Number <br /> W Facility's Phone: <br /> LOU 18c.Signature ofAltemale Facility{or Generator) <br /> Month Day Yetir <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI <br /> 2. 3. <br /> (i 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 /> Printed/Typed Name <br /> Signature Month Da <br /> U b� I <br /> EPA Form 870Q-22(Rev,3-0 Previous editions are obsolete. <br /> DESIGNATED F CILITY 0 ESTINATION STATE (IF REQUI EP) <br />