FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitch)typewnter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Ge a or D u r 2.Page 1 of 3.Eme ency Response Phone 4.Manifest Tracking Number WASTE MANIFEST A a�0 9 5 9 9 6 1 (8110)4249300 015481742 JJ K S.Ge atorsy and Mailing Address Generator's Site Address(If different than mailing address) eity of rarlteca City of Manteca 1001 West Center Street,Manteca,CA 95337 1077 Milo Candini Drive,Manteca,CA 95337 (209)456-8415 Attn: Greg Showerman Generators Phorre: 6.Transpo1 Com lame U. EPA bar _ / I 7.Transportifir2 Company Name U.S.E AID Number 8.Deugnated FaWM n;d-SBLAddress U.S.EPA ID Number 2500 West Lokern Road,Buttonwillow,CA 93206 (661)762-6200 CAD980675276 Facility's Phone: gra 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(it any)) No. Type Quantity Wt.Nol. 1. liNON-RCRA Hazardous Waste, Solids,(Lead) 0 0 1 D T 18 Y �t z 2 w I 3. i I 4. 14.Special Handling Instructions and Additional Information Sal: 95-1000/a Clean Harbors Profile Number: C H 13 12 3 0 7 B Vegetation 0-5% Wear appropriate Personal Protective Equipment as necessary 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, 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 Primary Exporter.I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmem of Consent. I certify that the waste minimization statement identified in 48 CFR 262.27(a)(if I am a large quantity generator)or fb)(dl am a small quantity Wrati is he. GeneratorsrOferor's Pnnted7ryped Name (on behalf of the City ofMatteca) Signature Month Day Year J 16.International Shipments f. ❑Importto U.S. Exportfrom U.S. Port of en /exit: Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Tr nen 1 Pnntedrryped N Signature /� 1 Month Day Year 0 lei 1 QTransporter2 Printetl(fyped Name SignatureMonty Day Year K H I 18.Disuepancy 18a.Discrepancy Indication Space El Quantity 1:1 Type ElResidue ElPartialRejection ElFullRejection Manifest Reference Number: 18b.Altemate Facility(or Generator) U.S.EPA ID Number J_ V LL Facility's Phone: w tuc.Signature of Alternate Facility(or Generator) Month Day Year Q Z w19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recyciing systems) G 1. 2. 3, 4. 2- 20. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item i8a Pnnted7Typed Name Signature Month Day Year v L '- EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)