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FtXM Approved. OMB No. 2050-003.9 ERATOR r UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />I. Generator ID Number <br />CAC 0 0 3 1 3 6 5 1 1 <br />-2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />244-234-2460 <br />4. Manifest Tracking Number <br />023134177 JJK <br />Generator's Name and Marling Address Generator's SiteAddress (if thlterent than maill' to address) <br />PG&E MANIFESTS PG&E STOCKTON <br />P0. BOX 7640 1049 S. Vv1L5ON V,AY <br />SAN FRANCISCO CA .94120 ISTOCKTal CA 95295 <br />Generator's Phonel 1 p o 0 1 ',-' n r. I 7 I <br />Transporter 1 Company Name U.S. EPA ID Number <br />PSC INDUSTRIAL OUTSOURCING, LP IC A R 0 0 0 2 6f•I 5 4 6 <br />Transpolar 2 Company Name U.S. EPA ID Number . _------__-, <br />I <br />Designated FaciGly Name and Sle Address e U.S. EPA ID Number <br /> <br />US ECOLOGY NEVADA - ' <br />HWY 115 11MI S OF BEATT( <br />eEATTY NV 89903 <br />Facets Phone:77 A 4? , ''',1-, :, 1 \ I 11 T '1 1 IT II I 11 n it .11 <br />9a. 9n. U.S. DOT Descripticn linchicEng Proper Shipping Name, Hand Class, ID Number, 10. Containers It. Total 12. Unrt <br />KA and Packing Group (if any)) Na. Type Quantity WINot. <br />13. Waste Codes • <br />.,., hlON-RCRA HAZARDOUS AP.STE, SOUD (POD CONTAMINATED 761. A sOILAND DEBR;S WTH 559PPM) <br />6 -j CM 4 GENI <br /> <br /> <br />14. Special Handing Insbuctions and Additional Information t..... <br />PROFILE 0 0703042,60-0 <br />JOB # 17B-2001-0002-32091 <br />e5,-W ,-,21 -a. .inE4# . <br />15, GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of Ns occsigunent are fully and.wozately daated above by the proper sNpping name, aid are classi5ed, packaged, ' <br />marked and labeted!placarded, and are in at respects In proper =ditto fcr transport according to applicable international and national governmental regulation. If mat shipment arid I an the Primary <br />Expo-tr, I certify that the =tents of this consignment conform to the terms of One etched EPAAcitriNteclgrnent of Consent <br />I certify that'll° waste minimization statement klentfiedln40 CFR 25227(a) (dl as a large quantity generator) a (b) (II am a small quantity generator) is Ube, <br />Generatoestifferres Printed/Typed Name t iCji, ep /4lgrgSgnatura , ktort Day Year <br />I ,..._ I f I 07 7/ <br />__I , 16. International Shi <br />import to U.S. Erport from US. Port of <br />Transporter signature (for exports only): Date le TRANSPORTER 1 TranspaterAcknowtedgment of Receipt of Materials <br />Transporter 1 Printed/Typed Nam, _....,e Signature Month .Day Year <br />....0. <br />__,....---•"*.e6e..th 7_ io. I ------------.--.-- ,x,?i-.„ i .21.2) Le, <br />Transporter 2 Printed/Typed Name Signature Month Day . ear <br />I I I I , .4-- DESIGNATED FACILITY, --). Discrepancy <br />18a. Discrepancy In:Web:in Spzm 0 Quaintly D Type LiResidue ElPartial Relation LIIFull Rejection <br />_ - - - <br />Manifest Reference Number: <br />at. Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility& Phone; I <br />18c. SIgnatuno of Alternate Facility (or Generator) Month Day Year <br />I 1 <br />Hazardous Waste Report Management Method Codes 0., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. VI: gra, 2. 3. 4. <br />Designated Facility Owner a Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted In Item 113a <br />Printed/Typed Name *natio I+1 Day Year <br />I I i 50 ret <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are cobs& . DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM