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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator lD Number 2.Page 1 of 3.Emergency Response Phone 4.M�gIt tt j�c g,�luyrbx. <br /> WASTE MANIFEST C A P 0 0 0 3 0 4 0 4 8 1 1844,334-2468 O y 111 r JJ K <br /> 5.Generators Name and Mallin Address Generators Site Address(ii different than mailing address) <br /> PG&E MANIFEST PG&E GTP R-1036 TRACY <br /> PO BOX 7640 37.76033-121.47930 <br /> SAN FRANCISCO CA 94120 TRACY CA 95304 <br /> Generators Phone: 9 2 5 2 2 4 - 3 6 6 8 <br /> 6.Trans orter 1 CompanyName U.S.EPA ID Number <br /> Pk INDUSTRIAL OUTSOURCING LP C A R 0 0 0 2 6 9 5 4 8 <br /> 7.Transporter 2 Company Name � ��� U.S.EPA A tD NUmbeV <br /> B pestonate�Fac�lttY Nam LLC l!1 U.S.EPA ID Number <br /> I 1 W5 V 11TE IK=RC AD <br /> RANCHO CORDO'VA CA 95742 <br /> Facility's Phone: 916 351-OW 1C A D 9 8 0 8 8 4 1 8 3 <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group Cif any)) No. Type Quantity WtJVd. 13.Waste Codes <br /> 1NON RCRA HAZARD"VMTE.SOLID 611 <br /> o (SOUDEBRIS CONTV~TED VATH OIL.DIESEL.AfERCAPTAM <br /> 0 0 1 DM OWW P <br /> W <br /> Z 2. <br /> W <br /> 121) <br /> 3 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 9B.1 492061 1X55 <br /> 116-1910-0008—J0002 PO# PGT1912116 <br /> 15. GENERATOR'S/OFFEROR'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 labeled/placarded,and are in all respects in proper conditim for transport according to applicable international and national govemmental 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 EPAAckrwwiedgment of Consent. <br /> I cert fy that the waste minimization statement identfied in 40 CFR 262.27(a)(H I am a large quantity general or ill am a small quantity generator)is true. <br /> Generators/Offerors Pintedfryped Name Signatirre Month Day Year <br /> DAVID M03ER ON BEHALF OF F4XE 0 2 4 0 <br /> 16.International Shipments <br /> F— ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLI <br /> Transporter 1 Printed/Typed Name Signa Month Day Year <br /> a <br /> DAVID MOSER 10204tO <br /> QT er 2 Printed/Typed Narne +,, Month Day Year <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manffest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rai Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and reading systems) <br /> 0 1. 2. 3. 4. <br /> 7 <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedfryped Nae Signature Month Day Year <br /> as 2 115 c <br /> EPA Form 8700-22(Rev.12-17 Previous editions are obsolete. ITEMNATEOFACILITY TO EPA's e-MANIFEST SYSTEM <br />