Laserfiche WebLink
cCg�, E E II D M <br /> Please print or type.(Form designed for use on elite(12. af!4(�? Form Approved.OMB"No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 1CA289009G002 11 925-423-420S 1005870881 JJ K <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than malting address) <br /> Lawromm Livermore National Labarawry Sift: 300 for NNSA Llvarencm 13vrnn-jre N&6znal Laboratz:nj Site 300 for NNSA <br /> P.0 go% 908 J L-786 Livermore CA 94551 Carrel Hvllvw Road, Tracy CA 95276 <br /> GenaratoesPhone 925-422-1915 A7FN- >,t�ninn <br /> 6.Transporter 1 Company Name U.S EPA ID Number <br /> (lean Harbors Environmental Samicas Eno. MAD03-4322250 <br /> 7.Transporter 2 Company Name US EPA ID Number <br /> 8.Designated Facility Name and Site Address U-S.EPA ID Number <br /> Clain Harbon Buttorrvrillow, LLC CAD980675276 <br /> ZSDO West team Hoar~+, Butinnwilfow CA 93205 <br /> Facilitys Phone 661-762-6200 <br /> ga. 9b.U.S.DOT Description(mcluding Proper Shipping Name,Hazard Class,ID Number, 10.Contalners I1 Total 12.Unit 13 Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtJUol. <br /> 1. <br /> iX 1/ Rq,TIA22a Asbeitos,9,111 JERG 1711 (DCIPOZ20e-ll <br /> ta.t <br /> t7 <br /> J <br /> r <br /> r <br /> 14.Special Handling Instructions and AddMnai information j <br /> EMei'g*rtcy Ftesponst Phone 92--y-4?3-4205 Contact name LLNL Emergency Grspatch. Load Nu.ETWL9-m Ship Dot No.5-237373, <br /> Reference release number LXEDLD9 on invoice. gt]=784. Sin No.CI-frfP20300. 531fAPCD—41M Enterprnce Way,Modesto, <br /> 95356 <br /> 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 dassified,packaged <br /> marked and labeled'placarded.and are in alt respects in proper condiltm 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 EPAAckrwwledgment of Consent. <br /> I certify that the vraste minimization statement identified in 40 CFR 262.27(a)(if I am a large quanftj generator)or(b)(if t am a small quantity generator)is true. <br /> rS:ccwrrr <br /> rsnbtferors Pdnted7yped Name Signature .Month Bay Year <br /> A- Graham or, behalf of NNSA ,l � � I Q1 Z4 I I R <br /> —j 16 intemabonal Shipments <br /> i- ❑Import to U S. ❑Export from U.S Port of entry.'exit: <br /> z Transporter signature(for exports only) Date leaving U.S.: <br /> w 17 Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1Psinied(Typeq/Name <br /> �,c Signature Month Day Year <br /> QTransporter 2 PrimediTyped Name Signature' Month Day Year <br /> a <br /> r- <br /> 18 Biscrepaacy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Referer ce Numbt-. <br /> 18b.Altemate Facility ter Generator) US EPA ID Number <br /> J_ <br /> C-1 <br /> tas- Faa'litys Phone: <br /> cm <br /> 18c.Signature of Alternate Facirty(or Generates) Month Day Year <br /> z <br /> Cn 19 Hazardous Waste Report Management Method Codes(L-e.,codes for hazardous waste treatment disposal,and recycling systems} <br /> T <br /> 20.Designated Facility Owner or Operator;Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a <br /> PnnTyped Name 1 y T signaure) i Month Day Year-, <br /> EPA Form 8700-22(Rev.3=05) Previous editions are obsolete. / - DESIGNATED FACILITY TO GENERATOR <br />