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Stole of Coliforms—Environmental Proleclion Agency <br />form Approved OMB No. 2050-0039 (Expires 9.30.991 - See Instructions on back o. ,9e 6. Department of Toxic Substances Coni <br />Please print or type. form designed for we on elite 112pitch) typewriter <br />C <br />v <br />n <br />C, <br />if <br />a <br />C <br />C <br />cX <br />U <br />LL <br />ti <br />Z <br />w <br />U <br />w <br />N <br />Z <br />O <br />V) <br />Q <br />Z <br />O <br />Q <br />Z <br />U <br />Z <br />LLJ0 <br />ne <br />LU <br />LLi <br />LL <br />O <br />Q <br />U <br />z <br />DO NOT WRITE BELOW THIS LINE. J.— <br />DISC <br />.- <br />DISC 8022A (1/99( <br />EPA 8700-22 „odes ,: .n.pp.n.•: •,I,r <br />t <br />1 Generator's US EPA ID No Manifest Docvment No. 2. Page I Information in the sbadsd areas <br />UNIFORM HAZARDOUS <br />is nal,equired by Federal law, <br />WASTE MANIFEST a1 <br />J. Generator's Nome and Moiling Address SIKI. Manifest Document Number <br />Lawrence Uvermom Natlonml Labormory Site 300 23440682 <br />P.O. Box 806 L -M B Slate Generator's ID <br />l,,lyq $4551)F 0 <br />2—�iS Ault' Ship <br />5 Transporter I Company Nome 6 US EPA ID Nvmber <br />C Stole Tronsportee's ID IReserved.1 <br />Lawrence Livermore NaC101TN1 LaL`uretory <br />D. Tronsporler'sPhone 925-123-1925 <br />7 Transporter 2 Company Name 8, US EPA`16"Atrtef V VA <br />E. Stale Transporter'& ID (Reserved.) <br />F. Transpwlcr's Phone <br />9. Designated Facility Name and Site Address 10 US EPA ID Number <br />G. Stole Facility's ID <br />Clean Hfartfors of San .loge, 111 <br />1021 SerryNS48 Roi;4 <br />H.,Fociliy's Phone <br />San CA 4'5.133 � Qal <br />Jose �Gl <br />._ - nrino <br />12. <br />11. US DOT Description (including Proper Shipping Nome, Hazard Class, and ID Nvmber) Containers <br />13. Tolyl 14. Unit <br />No <br />No. <br />Type Quantity WI/Vol 1. Waste Number <br />Nch- tCRA hazardous waute, liquid (ethox)4ated alcohols,. <br />stale <br />IrimatWhexanole acid) (S.984,02I) <br />7 <br />_ <br />G <br />134 <br />EPA/Other <br />E <br />N <br />b. <br />State <br />E <br />EPA/Olhor <br />R <br />� <br />I <br />L <br />T <br />Slate <br />O <br />EPA/other <br />R <br />d. <br />Stole <br />4� <br />EPA/Other <br />). AdditionoN. escriplfons for Materials Listed Above <br />K. Handlin Codes for Wostes listed Above <br />o. <br />e. A00087263r 000090015, 00006925]., 000089172, 000099297, OC10099734, <br />000200393 <br />+� <br />Ed <br />\\Qj� <br />� 0,-l.J I�:J! � <br />15. Special Handling Instructions and Additional Information <br />LTJ& Ship doc !0 F-6041.5 . 6Naz.' protective clothing chile 144ndlirq. Yhe!c osntarialts are not <br />radioactivelyicontxninated. Reference re•leaae 9 LAI -0530. f Cmorgenny Contact: <br />9Z5-447-6890 <br />T6, GENERATOR'S CERTIFICATION: I heroby declare that the contents of this consignment are Cully and accurofely dascribedobove by proper shipping name and ore classified, pocked, <br />marked, and labeled, and are in all respects in proper condilion lot sronsparl by highway according to applicable into rnat-cit and national gavernmenl regulations <br />III om a large quantity generator, I certify that I hove a program in place to reduce the volume and toxicity of waste generaled to the degree I have determined to be economically <br />practicable and that I have selected the Qracsicoble method of treatment, storage, or disposal currently available to me which minimizes the present and Ivture threat to human health <br />and she emironmeni, OR, if I am a loin❑ gvanlity generator, I have mode a good loilh ellarl to minimize my waste generation and salecs the best waste manngement method that is <br />available to me and that I can afford. r% <br />Printed/Typed Nome <br />Signature (/� <br />/ <br />Month Day,/ �Y1ea. <br />t }/. <br />li' <br />jN- •x.•`.1-•1, <br />l.� <br />T <br />17. Trans otter I Acknowledgement of Receipt of Materials <br />A <br />A <br />Prinled/,F ed Nome <br />Si nalura _ <br />Month Day Yco <br />P/ <br />,/, les r• �P..�`r� . <br />-•/l =�c �^_v+-rte. - .. <br />A <br />Transporter 2 Acknowledclemeril of eceipl of Materials <br />Name Signature Month Day Yeo <br />T <br />Prinled/Typed <br />f <br />19. Discrepancy Indication Space <br />E <br />A <br />�tECE1VEp <br />C <br />I <br />l <br />20. Facility Owner or Operalor Certification of receipt of hazardous materials covered (his manifest except as noted in Item 19. __ <br />Month Day ec <br />T <br />Y <br />Printed/ Typed Name Signolwe S _ <br />r'--� <br />DO NOT WRITE BELOW THIS LINE. J.— <br />DISC <br />.- <br />DISC 8022A (1/99( <br />EPA 8700-22 „odes ,: .n.pp.n.•: •,I,r <br />t <br />