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Please prin?6ir type.(Form designed for use on elite(12-pitch)typevaiw.} Form Approved.OMB No 4.2050-0039 <br /> UNIFORM-HAZARDOUS r Generator ID Number 2.Page 3 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> 'WASTE MANIFEST CA2gg009000? L 192S-423-420S 11 r�f JJK <br /> L S.Generator's Name and Mailing Address Generator's Site Address(d different than mailing address) <br /> tzwencr Lveni ury National Laboratory Slim- 30'; for NNSA Lawrence Lrverm:7re Natonai Lalocrato ? Site 200 for NNSA <br /> P.O. Box SLV 1 L-796 Lrvrnmure CA 94551 Cora, 14o"aN Flo-ad. Trzn4 CA 94551 <br /> GeneratoesPhone: 425-432-1925 Ar.-N.tr„— <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harborrs Environmental Services Inc- tAAD039322-2-.0 <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> � jr Sf+, fr 1"P��ur �__ rel:- r-{UL►G`1)-G?�ti`1y <br /> S.Designated Fatifty Name and Site Address U.S.EPA ID Number <br /> Clean Harbors Mrrltngt—on, LLC CAD044429835 <br /> Denni Stied Wilmin iton CA 90744 <br /> Facility's Phone. 3ID-935-g9gg <br /> ga 9b.U S.DOT Description(inducing Proper Shipping Name,Hazard Ctass,ID Number, 10 Contx ers 11 Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(it any)) <br /> 4o Type Quantity NlLNoi. <br /> 1 <br /> o Nan-- RA hazardous waste,liquid(USED OIL I(OCIPt7080-1) ;:, F <br /> 221 <br /> z z. <br /> Noll-RCRA hazardous waste,liquid(USED oil)tMPI0030-1) <br /> 221 <br /> 3 <br /> 14.Special Handling Instructions and Additional Information <br /> Emergency Response Phone.925423-4Z)5 Conte-_-nafre UNL En-ergene}'Cisspatch <br /> Load No. WIL18-OZ Ship Go--No.5-231148, Ref_fenCr re{ea>e number vilt ]A Oil iitwov-e- 5v---at,aj*d for war ar mf uumbef-E <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 das0ed packaged. <br /> marked and Iabeledrplacarded,and are in all respects in proper condition for transport accordmi;to applicable intemational and national governmental regu ations.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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262,27(a)(if I am a-arge quantify generator)or bI rif I am a small quantity goneralori i�true <br /> Genefator'VIXerors Printed+Typed Name Signature Month Day Year <br /> Scott A- Graharin an behalf of NN-A <br /> --r 16.Intematonal Shipments <br /> E- ❑Import to U.S. ❑Export from U.S. Port of entry,'exit: <br /> ? Transporter signa'.ure(for exports only): Date leaving U S. <br /> 17.Transporter Acknowledgment of Receipt of Materials y ; <br /> Transporter 1 PnntedrTyped Name Signature { Month Day Year <br /> 17 <br /> Cn <br /> a Tran'sp6rier2P nte' Name' Month Day Year <br /> 1-1L�✓/ .ice . =f +� �f }r+. .{ s�.�FiLI -7 -, <br /> /P <br /> 16a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue Partial Rejection ❑F,.'I Rej,-,Lor, <br /> Manifest RVerence Number <br /> 18b.Alternate Facility,(or Generator; US EPA ID Number <br /> C� <br /> Faciivs Phone <br /> W 18c.Signature of Alternate Faculty for Generator) Month Day Year <br /> a <br /> z <br /> 19 Hazardous Waste Report Management Method Codes(.0.codes for hazardous waste treatment.disposal,and recycling systems; <br /> 0 1. 2 3. a <br /> Isti i t <br /> 20 Des gnated Facl:ty Owner or Operator Carblicatirm of receipt of hazardous materials covered by the manifest except as noted in Item 16a <br /> PnntedrTvped Name Signature rr" Day )rtar <br /> EPA Form 8700.22(Rev 3.05: Previous editions are obsolete DESIGNATED FACILITY TO GENERATOR <br />