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Please print or type. Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.M If��ff t c ' u <br /> WASTE MANIFEST C A P 0 0 0 3 0 4 0 4 8 1 844-334-2468 1 2 5 JJ K <br /> 5.Generator's Name and Mailln Address Generator's Site Address(if different than mailing address) <br /> PG&E MANIFEST PG&E GTP R-1036 TRACY <br /> PO BOX 7640 37.75033-121 A7930 <br /> SAN FRANCISCO CA 94120 TRACY CA 95304 <br /> Generator's Phone: 92 5 2 2 4 - 3 6 6 8 <br /> 6.Transporter 1 Compan Name U.S.EPA ID Number <br /> PSC INDUSNIAL OUTSOURCING LP I C A R 0 0 0 2 6 9 5 4 8 <br /> 7.Transporter 2 Company Name U.S EPA ID Number <br /> 8.DesianatedEeWANam3and St[eAdft,,A.LLC U.S EPA ID Number <br /> 11855 HYHITE ROCK ROAD <br /> RANCHO CORDOVA CA 95742 <br /> Facility's Phone:916 351-0980 C A D 9 8 0 8 8 4 1 8 3 <br /> ga, 9b U S,DOT Description(including 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 /> 1NON RCRA HAZARDOUS MSTE.SOUD 611 <br /> o (SOIUDEBRIS CONTAMINATEDWTH OIL.DIESEL.MERCAPTAM <br /> 0 0 1 DM 00300 P <br /> Z 2 - <br /> w <br /> C) <br /> 3. <br /> 4 <br /> r <br /> 14.Special Handling Instructions and Additional Information <br /> 9B.1 492061 1x55 <br /> 116-1910-0008-J0002 FO# PGT1912116 <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 labeledlplacarded,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 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity genera or Wif I am a small quantity generator)is true. <br /> Generator's/Offeror's PrintedfTyped Name Signature Month Day Year <br /> DAVID MOSER ON BEHALF OF PG&E 1 10 2 P 4_9 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 /> Transporter 1 PrintedfTyped Name Signatu Month Day Year <br /> CO DAVID MOSER 0 2 4 0 <br /> Z Transporter 2 Printed/Typed Name Signatur Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Numbor. <br /> 18b Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> LL Facility's Phone: Month Day Year <br /> LU t&.Signature of Alternate Facility(or Generator) <br /> ZZ <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> en <br /> 0 1 Z. 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 /> PrintedfTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />