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<br />C...... A.,..«.,.,,a nxAo nr.. nnen nnon
<br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. t `i) i:11.t!.ii'r fC' t ::,";, 1.';t;'�id `;11\1'f_ (P' I;l_fallint_D)
<br />UNIFORM HAZARDOUS
<br />1. Generator ID Number
<br />2. Page 1 of
<br />3. Emergency Response Phone
<br />-t005870331
<br />4. Manliest Tracking Number
<br />WASTE MANIFEST
<br />CA2890090002
<br />925-422,1
<br />JJ K
<br />5. Generator's Name and Mailing Address Generators Site Address (if different than malting address)
<br />Lawrence Livermore National Laborator; Site 300 for NNSA
<br />Lawrence Livermore National Laooralonj Site 38'0 ror.NmSk
<br />P.0- Box 8081 L-786
<br />Corral Hollow Roar]
<br />Livermore CA 94551
<br />Tracy CA 95370
<br />Generator's Phone: 925-422-1925 Attn: 3ftin in
<br />6. Transporter 1 Company Name _ 11 F',y U.S. EPA ID Number
<br />I..nm �
<br />'
<br />Clean Harbors Environmental Services Inc. `, MAD0393222�a0
<br />7. Transporter 2 Company Name U.S. EPA ID Number
<br />8. Designated Facility Name and Site Address U.S. EPA ID Number
<br />Clean Harbors of San Jose, LLC
<br />1021 Elerryeasa Read ENVIRON",'ENTAL
<br />San Jose CA 951.33HE,�LTH i; i';'MTPJENT CAD059494310
<br />Faci s Phone:
<br />8e,
<br />9b. U.S. DOT Description (Including Proper Shlpping Name, Hazard Class, ID Number,
<br />10. Contalnera
<br />11. Total
<br />12. Unit
<br />13. Waste Codes
<br />No.
<br />Type
<br />HM
<br />andPecking Group 0 any))
<br />Ouantlty
<br />WtNol.
<br />1R©, UN 1219, Waste, Isopropanol, 3,11 (RD DG01) [ERG 129]
<br />212
<br />c
<br />(DOPG054-1)
<br />1DH
<br />-
<br />Lq@7
<br />�,
<br />p
<br />!.
<br />ii ;
<br />D001
<br />2-UN1203, Waste, Gasoline, 3,11 [ERG 1281(DOP0054-1)
<br />214
<br />X1
<br />1
<br />m3
<br />12
<br />P
<br />noel
<br />3'UN1993. Waste, Flarnrrlable liquids, n.o.s. (acetone, ethyl acetate), 3, II
<br />134
<br />X1
<br />[ERG 1281 (DOP0054-1)
<br />1
<br />p"
<br />44
<br />P
<br />---
<br />Do01
<br />4 -UN 11993, Waste, Flammable liquids, n.o.s., 3, II (lab pack) [ERG 128]
<br />331
<br />(DOP011 B-1)
<br />1
<br />pg
<br />$
<br />p
<br />--
<br />-
<br />-
<br />Deal
<br />14. Special Handling instructions and Additional Information
<br />Emergency Response Phone 925-423-4285 Contact name LLNL Emergency Di atch.l3
<br />Load * SA 5-24, Ship Doc No. S-202153, Reference release number LSJ 0375 on imfoice.
<br />See attached for container numbers.
<br />15. GENERATOR'SlOFFEROR'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 labeledlplacarded, and are in all respects in proper condition for transport according to appacable inlematonal 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 lemrs of the attached EPAAcknowledgmenl of Consert
<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 />GeneratoesfOfferofs PrintedlTyped Name Signature Month Day Year
<br />16. International Shipments ❑ Export hem U.S. Port of en t:
<br />El Import to U.S. entry/exit
<br />Transporter signature (for exports only): Date leaving U.S.:
<br />17, Transporter Acknowledgment of Receipt of Materials
<br />Name Signa Month Day Year
<br />Trrnder 1 PrintediTyped
<br />Tr nsporter 2 PdntoOTyped Name M05th Day Year
<br />ppQ�
<br />F-
<br />18. Discrepancy
<br />18a. DWepancy Indication Space ❑ Quantity ❑Type ❑ Residue ❑ Partial Rejection ❑ full Rejection
<br />Manifest Reference Number.
<br />18b. Alternate Facility (or Generator) U.S. EPA ID Number
<br />U
<br />I
<br />Facifitys Phone:
<br />C3
<br />18c. Signature of Alternate Facility (or Generator)
<br />Month Day Year
<br />X
<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />C
<br />1.
<br />2.
<br />3.
<br />4.
<br />20. Designated Facility Owner or Operator. Certification of recelpt of hazardous materials covered by the manifest except as noted in Item 18a
<br />Printed7Typed Name Signature Month Day Year
<br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. t `i) i:11.t!.ii'r fC' t ::,";, 1.';t;'�id `;11\1'f_ (P' I;l_fallint_D)
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