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<br />Please Dnnt or tvoe. Form Approved. OMB No. 2050-0039 a GENERATOR ..
<br />UNIFORM HAZARDOUS 1. Generator ID Number
<br />in f; 1 .1
<br />2. Page 1 of 3. Emergency Response Phone
<br />N4-334-2488
<br />4. Manifest Tracking Number
<br />023135757 JJK
<br />Generator's Name and Mailing Address Generator's Site Address (if different thar
<br />Pr4.,P,E MA fki IF ESTS PG&E STOCKTON
<br />P.n. BOX 7P4n 104g S. WILSON ',Ma
<br />.;/-.'.N F RAN C1:7-;CO CA !7_441 20 1 STOCI<TON CA g5205
<br />Generators Phone: ..-, n n •-.., .-,-.7. n .iri a -i
<br />mailing address)
<br />-. 1 ' Transporter 1 Companf NaiMe- - - - -
<br />-..._•-•:-,--,-.,
<br />U.S. EPA ID Number
<br />C. 1.‘48.00 12• I Vs./31 - _,.,
<br />... ,,,.._, : [ ,,, ..._ s: I -: ::: : T.
<br />Transporter 2 Company Name JAA...at t.:51.--- tp-A.C.t....SA-17..LA..-04.71S.m.)124-4-&-tp: U.S. EPA ID Number osmoci,2496,4.6,
<br />+&411.-eez.-1-604-1-1-- €0, - ,- et •
<br />Designated Facility Name and Site Address
<br />EVW gf: 1 i MI S OF RE:-.ATTY
<br />E :=..ATTY NV 80003
<br />Facility's Phone: 77 0 ..,...,7.:. ..".1 no
<br />U.S. EPA ID Number
<br />I f‘,1 ,./ T '11 '. p n -1 n n r; I",
<br />ga: 9b. U.S. DOT Description(Inc-It:ding Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes
<br />NM and Packing Group (if any)) No. Type Quantity WL/Vol
<br />1 NI ON-RCRA HAZARDOUS WA.STE, SOLID (FOB CONTAM)NATED K.
<br />t
<br />"dr Iv
<br />SOILAND DEBRIS \MMI 650PPI$.4) 0 % CMrti7 I >fir"'
<br />
<br />
<br />
<br />14. Special Handling Instructions and Additional Information
<br />PROFI LE. # 070204760-0 _
<br />SALES ORDER #210819143R
<br />B.104‘7. 8°1
<br />_
<br />--1)e,./Def-- .1nR.,* 2-2.-14,0qt
<br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above
<br />marked and labeled/placarded, and are in all respects In proper condition for transport according to applicable international and national governmental
<br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Aclmowledgment of ConsenL
<br />I certify that the waste minimization statement identified In 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (ifl am small q ntity generator)
<br />)y the proper shipping name, ant are classified, packaged,
<br />regulations. If expect shipment and lam the Primary
<br />is true.
<br />Generators/Offerors Printed/Typed Name Signature
<br />OA ,lip IdtiNiZd 6 43 I 13
<br />Month Day Year
<br />1 31 I 02 _,
<br />F
<br />16. International Shipments ..,
<br />Import to U.S. Export from U.S. Port of entry/exit:
<br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials
<br />Iran rter 1 Printed/Typed Name Signe e ,,,,
<br />Us_......-ja---
<br />Month Day Year
<br />5 I. 1 13 I
<br />1
<br />Trans er 2 Printed/Typed Name Signs
<br />I
<br />mdtii as 4.../.
<br />Ect+04-44-1.,7,2.c. I 4- DESIGNATED FACILITY 18. Discrepancy
<br />Discrepancy Indicafion Space Quantity Type Residue
<br />Manifest Reference Number.
<br />Partial Rejection Full Rejection
<br />Alternate Facility (or Generator)
<br />Facilitys Phone:
<br />U.S. EPA ID Number
<br />I
<br />Signature of Altemate Facility (or Generator) Month Day Year
<br />I I
<br />19. Hazardous ste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />1.
<br />• 32
<br />2. 3. 4.
<br />20. D 1 ted lay Owner 'r Opera . Certification of receipt of hazardous materials covered by the manifest ex dud i em 18s (5
<br />ii0 A zilittAY/
<br />I ture 13 ' d ame Signa .
<br />(VICUtt Ilrth
<br />Day Year
<br />I 27
<br />EPA Form 8700-22 (Rev. -17) Pr4etjWdons are obsolete. D S NAT AC TO EPA s e-
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