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Please print or tvoe. (Form desioned for use on elite 112-oitrhl tvnP.wr;tPr t EPA Form 87OU-22(Rev.M5) Previous editions are obsolete. hr_ SIG;JAlF--D FACII.IT710 rESTINATION STATE (IF nEQUIRED) UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone ,,,.rr,�•��. �,•,� .�. ��-�� 4. Manifest Tracking Number WASTE MANIFEST CA2890090002 2 925-423-1205 1005870341 JJ K 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) Lawrence LNermore National Laboratory Site 303 for NNGA P.O. BOX 8081 L-786 Lawrenceu;zrnlore nlattonal LaDoratory Wirtz 300 for NrdSF. Livermore CA 94551 Corral Hnitow Roaa t na TraCy CA 95376 GeneratofsPhone: 923-422-1913 Attn: Shii 6. Transporter 1 Company Name,� U.S. EPA ID Number Clean Harbors Errolronmental Services Inc. ;' r19�;D0�9�222 0 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Slte Address U.S. EPA ID Number Clean Harbors of San Jose, LLC 1021 Berryessa Road ENVIRONMENTAL San Jose CA 95133 HE.�LTF" fP^�iTIJENT 4aaDe��9�o-931a"e Fad(I s Phone: ga. gb. U.S. DOT Description (Inciud!ng Proper Shipping Name, Hazard Class, ID Number, 10. Contalners 11. Total 12. Unit HM end Packing Group Of any)) Quantity WI.NoI. 13. Waste Codes No. Type 1UN 1814, Waste, Potassium hydroxide, solution, 8, II (ERG 154] 0 (DOP0015-1) 122 naa2 i DF 75 PQi 2-UN3288, Waste, Corrosive liquid, basic, inorganic, n.o.s., 8, 111 (Lab 122 pack) [ERG 154] (DOP0114-1) 2 DF 287 P D002 3Nan-RCRA hazardousvuaste, liquid (USED OIL) (DOP0080-1D)221 1 D14 480 P 4.Non-RCRA hazardous waste, liquid (poly alkysiloxane solution) 331 (DOP001Q-1) i DF 44 P 14. Special Handiing Instructions and Additional Information Emergency Response Phone 925-42311205 Contact name LLNL Emergency Dispatch.0 Load # SA 0-08, Ship Doc No. S-202798, Reference release number LSJO386 on invoice. See attached for container numbers. 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, marked and labeledlplacarded, and are in all respects in proper condition for transport according to appficable IntemaQonal and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the temrs of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identiFed in 40 CFR 26227(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is Generators101feroes Printed/Typed Name Signature Month Day Year J Z 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: Transporter signahoe (for exports only): Dale leaving U.S.: W 17, Transporter Acknowledgment of Receipt of Materials Trans r 1 PdntfTyped Name ,Q / Sg re Month Day Ygar a rn r .� / C- d % j 1 711( Z TranWer 2 Prin Name Sig ure Month Day Year Cr F- 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Attemate Facility (or Generator) U.S. EPA ID Number 7 U rai Faa7itys Phone: LL, 18c. Signature of Alternate Facility (or Generator) Month Day Year ZZ y1g. Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems) 0 1. 2. T. 4. 1 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 87OU-22(Rev.M5) Previous editions are obsolete. hr_ SIG;JAlF--D FACII.IT710 rESTINATION STATE (IF nEQUIRED)