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'1 Please print Or type. A IC5 12 UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator iD Number CAC() 0 2 1 3 6 5 I 1 2. Page 1 of 3. Emergency Response Phone 344.3342468 4. Manifest Tracking Number 023134173 JJK Generator's Name and Maiti gAdoress Generator's Ste Address (if different than mailing address) PG&E MANIFESTS PG&E STOCKTON F.Q. BOX 7640 1049 S.. IMLSON WAY SAN FRANCISCO CA 94120 , rSTOCKTON CA 05295 Generators Phone: i 9 a 0 "a 0 r, 1' 7 I Transporter 1 Company Name U.S. EPA ID Number PSC lls4DUSTREAL, OUTSOURCINe, LP °' , IC A R 0 0 0 2 0 g 5 4 8 7, Transporter 2 Company Name ' U.S. EPA ID Number . , S. Designated Facility Name and Site Address " ' rr U.S. EPA ID Number U S ECOLOGY NEVADA HWY 05 11MI S OF BEATTY 2EATTY NV 899i23 , Facility's Phone:T-7c cc: Tr,. n o IN I 11 1.-•• 2 q n n 1 n n fl 1 ga. 96. U.S. DOT DescTrip-tron (-incl- ird- ing Proper Shipping Name, Hazard Class, ID Number, ' 10. Containers 11. Total 12. Unit NM and Par-1909 Gruff:. Qi aftY))13. No. Typa Quantity . .1b1..Nol. Waste Codes X 140N-RCRA HAZARDOUS WASTE, SCUD (PCB CONTAMINATED 761 BOILAND DEBRIS W111-1 85OPPM) 0 1 CM /0, 600 K m 4.1 0 2. 3. a Special Handling Instructions and Additional Information 8 ,1/ 9 y PROFILE # 070304260-0 JOB' # 178 —2001-0002—L320Si , GENERATORS/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, an am ciassitied, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and nationaI governmental regulations. if export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I Mr a iarg6 quantity generator) or (b) (if I am a small quantity generator) is true. Generator's/Offerors PrintedlTyped Name 0 iL, Szaillire_F a-F. 04 g• Signature Month Day Year I i —_ ItokIXSia\ I _r f-LJlnnpoiltou,S. International Shipments 11 III Export from U Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER- Transporter Adrnowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year 1....."2---.. ,L....— _ I° P. UV ai Transporter 2 Print yped Name -. n re Month Day Year I II I 4--- DESIGNATED FACILITY --0. Discrepancy ., 16a. Discrepancy Indication Space Quantity Type ; LRes'iduei - 7 Partial Rejection Fell Rejection 1 4 . Manifest Reference Number - rib. Alternate Facility (or Generator) U.S. EPA ID Number ' Facility's Phone: I 18. Signature of Alternate Facility (or Generator) ,. , 1 - I - Month Day Year • I I 19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1. 1 7-L3a. 2. 3.. 4. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials vered by the manifest except as noted in Iterille, Printed/Typed Na Signa.........................-- MiOir .....4._' , I ( . --- Fats t 6Ye.a4 EPA Form 5700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM