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State of California—Envirpnment Protection Agency – -) <br /> Form Approverd .�o rao. SQ40039(Expires 9-30-94) • 6-ge-lns fictions on back o <br /> Please print or type. Form designed for use on elite(12-pitch)typewriter. 9e 6' et went of Toxic Substances Corr <br /> - - Sacramento,California <br /> UNIFORM HAZARDOUS 1 Generator's US EPA ID No. Manifest Document No. 2. page 1 Information in the shaded areas <br /> WASTE MANIFEST 0 0 0 2 9 is not required by Federal law. <br /> 2 8 <9.0 0 9 4 2 3 7 of '1 <br /> 3. Gene'rator's Name and Mailing Address <br /> W) Lawrence Livermore National Laboratory, Site 300 <br /> N 7000 East Avenue, Livermore, CA 94650 <br /> to 4. Generator's Phone (510) 422-1925 Attn:A. Wilt L-820 <br /> 0 5. Transporter 1 Company Name 6. US EPA ID Number <br /> 0o Erickson, Inc <br /> 7. Transporter 2 Company Name Cl Al DI 010191 41616 3 9 28. US'EPA ID Number <br /> Q <br /> U <br /> Q 9. Designated Facility Name and Site Address <br /> 10. US EPA ID Number <br /> Z <br /> ERICKSON INC. <br /> (O!L 255 Parr Blvd., Richmond, CA 94801 g <br /> 8 <br /> M/e��v <br /> oC A D 0 0 8 4, 8 31912 , <br /> .. <br /> c�y0 Z 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12• Containers 13. Total 14. Unit <br /> 00 Z No. T e Quantity Wt/Vol <br /> C\J t: Non RCRA Hazardous Waste,Solid (Empty Containers Last Containing <br /> 4M� E Diese►Fuel)(With associated piping} 00 1 TP 0 2 0 p <br /> 06o N b. <br /> 00 E � <br /> i t <br /> v R - '- <br /> A1 <br /> o ti <br /> 0 T C. <br /> 00O <br /> R <br /> w <br /> Z d. <br /> WijZ <br /> U a. <br /> LU <br /> N e' <br /> Z <br /> 0 dihonuf rjttb'� QSr, _ a. .,. <br /> W <br /> LU , <br /> Z <br /> 0 15. Special Handling Instructions and Additional Information 6. QVeAl <br /> a EMERGENCY CONTACT: (510) 447-8880.1 IT Job# 152298 <br /> Z Wear protective clothing while handling These materials are NOT radioactively contaminated. <br /> F HWM Requisition Number H 135771 7.AAJK S a y DIV( <br /> J 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br /> Q packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable federal,state and international laws. <br /> U „ n <br /> If I am a large quantity generator, I certify that I have a program in p1hce 40 lrtdufe the volume and,toxicity of waste generated to the degree I have determined to be <br /> economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> threat to human health and the environment;OR, if I am a small quantity generator, I have made a <br /> N 9 tY9 good faith effort to minimize my waste generation and select the be <br /> waste management method that is available to me and that I can afford. <br /> 0 Printed/Typed Name Signature Month Da ear <br /> } Richard B Loden on behalf of LLNL a <br /> V T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> LU R <br /> A Printed/Typed Name Signa <br /> (/y <br /> N p Month Da 9Year <br /> LU s �f�/Yl G o r uG Z O '7 / <br /> P <br /> o I8. Transporter 2 Acknowledgement of Receipt of Materials <br /> LU j Printed/Typed Name Signature <br /> LL- E Month Day Year <br /> 0 R <br /> w 19. Discrepancy Indication Space <br /> to <br /> U A <br /> 20. Facili Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Pr'nt ,/` Name <br /> Y Y Si re Month Day.�- Year <br /> L) L� <br /> 7 Z R <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (7/92) (Generatorswhosubmit hazardous waste for transport out-of-state, i <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />