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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS <br /> _TT__ID Number 2.Page 1 of 3.Emergency Response Phone 4.M If t c u <br /> WASTE MANIFEST C A P 0 0 0 3 0 4 0 4 8 1 844-334246 0 JJ K <br /> 5.Generator's Name andMallin Address Generatols Site Address``d�different than mailing address) <br /> PG&E MANIFESTS PG&E GTP R-1036 TRACY <br /> PO BOX 7640 37.75033 A 21 A7930 <br /> SAN FRANCISCO CA 94120 TRACY CA 95304 <br /> Generator's Phone 92 5 2 2 4 - 3 6 6 8 <br /> -6--T <br /> Transporter 1 Corn Name U.S.EPA ID Number <br /> PSC INDUS'WRL OUTSOURCING LP iC A R 0 0 0 2 6 9 5 4 8 <br /> 7.Transporter 2 Company Name U.S EPA ID Number <br /> 8.DesiMatedEecilitY NeIlr fl3r]d�e,Q(IQS4 VA.LLC U.S.EPA ID Number <br /> 0131E OF fi/1NG1'1ROCKv`:(JR ADL7D <br /> RANCHO CORDOVA CA 95742 <br /> Facility'sPhone:916 351-OWCAD $ 8 0 8 8 4 1 8 3 <br /> ga, gb 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.Nol. <br /> 1NON RCRA HAZARDOUS MSTE.SOLID 611 <br /> o ISOIUDEBRIS CONTAhNNATED VATH OIL.DIESEL,MERCAPTAM <br /> 00 1 DM 00300 P <br /> z 2 <br /> w <br /> 0 <br /> 3. <br /> 4 <br /> r <br /> 14.Special Handling Instructions and Additional Informabon <br /> 9B.1 492061 1X55 <br /> 116-1910-0008—J0002 POII 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity genera ar Nil I am a small quantity generator)Is We. <br /> Generator'slOHeror's Printed/Typed Name Signature Month Day Year <br /> DAVID MOSER ON BEHALF OF PG&E 0 2 4 0 <br /> 16 International Shipments <br /> ~ U Import to U.S. Export from U S. Port of entry/exit: <br /> M Transporter signature(for exports only). Date leaving U.S.: <br /> W 17 Transporter Acknowledgment of Receipt of Materials <br /> wMonth Day Year <br /> Transpoder 1 PnntedrTyped Name Si¢natd <br /> CO DAVID MOSER - 0 2 0 4 t 0 <br /> Z Transporter 2 Prmted/Typed Name Slgnatur Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space I__I Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reforence Number <br /> 18b Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> oFacility's Phone: Month Day Year <br /> LU t 8c.Signature of Alternate Facility(or Generator) <br /> Q <br /> Z <br /> N19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 <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 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 />