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Please print or type. ERATOR UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number 2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />. 800-839-3975 <br />4. Manifest Tracking Number <br />023134177JJK <br />Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />PG&E STOCKTON 1049 S WILSON WAY <br />PO BOX 7640 STOCKTON CA, 95295 <br />SAN FRANCISCO CA, 89003 <br />Generator's Phone: 844-334-2468 I Transporter 1 Company Name U.S. EPA ID Number <br />PHILIP WEST INDUSTRIAL SERVICES I CAR000269548 <br />Transporter 2 Company Name U.S. EPA ID Number <br />I <br />Designated Facility Name and Site Address U.S. EPA ID Number <br />US ECOLOGY NEVADA, INC. <br />HWY 95 11 MILES S. OF BEATTY NVT330010000 <br />BEATTY NV, 89003 <br />Facility's Phone: 800-590-5220 I <br />ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br />HM and Packing Group (if any))13. No. Type Quantity Wt.Nol. Waste Codes <br />SOIL, ASPHALT, CONCRETE AND DEBRIS CONTAMINATED WITH 514PPM PCBS - <br />TSCA SOURCE 1 CM 16000 K <br />261 .4 GEM <br />I-1 <br /> <br /> <br />14. Special Handling Instructions and Additional Information <br />15. GENERATOR'S/OFFEROR'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 labeled/placarded, 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 generator) or (b) (if I am a small quantity generator) is true. <br />Generator's/Offeror's Printed/Typed Name Signature Month Day Year <br />MICHAEL 1 MICHAEL I 08 I 27 I 2021 <br />.,J <br />3. <br />16. International Shipments Import to U.S Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />ce LL.1 1,2 <br />CD a_ u) Z ¢ <br />ce I- <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />MICHAEL P I MICHAEL P <br />I " <br />I 27 I 2021 <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />I I I I I 4-- DESIGNATED FACILITY -- 18. Discrepancy <br />Discrepancy Indication Space Quantity laPe Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: I <br />Signature of Alternate Facility (or Generator) Month Day Year <br />I I I <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />H132 <br />2. 3. 4. <br />20. Designated Facility Owner or Operator. Certifica on of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />JNUNFIO I JNUNFIO I 08 I 30 I 2021 <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM