COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

KE1LI ) Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS I'-Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CA2890090002 ) 11325-423-420S100,9R70808 JJK 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) Lawrence Livermore National LabaraL-f-I4!ts 3QQ for NN4A Lawrence Uvesrnore Natlicnal Lalaoratory Snte 300forNNSA P.0. Brix 2591 L-796 Livermore, CA 4d551 Ccm1 14ollaw Arad, Fray CA 915376 Generator's Phone: 9254Z2-1�25 ATTN-Shieaine 6.Transporter 1 Company Name U.S.EPA ID Number Clean Harbors Environmental Services Inc- MA00393222SO 7.Transporter 2 Company Name U.S.EPA ID Number tl.Designated FacilityName and Site Address U.S.EPA ID Number Clean lN-id*crs Buttorriwilfa*i.LLC CA09$0575276 Z500 West Loliiem pond ®sttrrn-.vA!uw, CA 93206 FacliitysPhone: Fc-ii.7r.t-Aron ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unit HM and Packing Group(if any)) No. Type Quantity Wt Nol 13,Waste Codes 0 1' Nan-RCKA hazardous waste,solid(non-PCH rapa;rors) 3 fly} ❑„q 273 2 Nan-RCRA hazardous waste.solid(non+CE r:apacnors) OM SAD 223 3.Non-RCRA hazardous waste.solid(ncrn-PCB capacitors) 7rn 223 4. Pion-F(CRA hazardouiwaste,solid jnen-PkE capacitors) CW 4iS7 tD:PM234.) 223 .14_Special Handling Instructions and Additional Information Em"tnci Respon;e Vttrner9i5-LI3. 205 Ccnzact narpie.t1.NL,gmergi ncyr Dtspatrh - Load No. STWL6-06, Shia OOC No.=-229324 . ft6}srarlca r�ltaSe nutrlber L547&57 ufl tnYtv!_e. 5��tii�:llr�ie}f i��ntatncrnuri� fi 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 marked and Iabelediplacarded,and are in all respects in proper condition for transport according to applicable international and national govemrrental regs!aaens.If export shipment and am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the aStached EPAAckrwwledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 26227(ai i if 1 am a large quantity generator)or(b)(if I am a sma!I quantity generator)is" Generator'slOtferor's Printedlryped Name Signature f/<�j Month Day Year Scott A- Graham an behalf of NNSA a j b r: 11 g J 16.Intema'aonalShipments � �-Y s ❑Import>4 U.S El Exportfronttf;5� Port orenb}n'exi1: Transporter signature(far exports only): Dare leaving U S.: w 17.Transporter Acknowledgment of Receipt of Materials TrarySpgRer 1 Pnntedliyped Name �5ignat re Month Day Y ar Q TrAnsporter 2 Printedfryped Name Signature [ Month Day Yeet t- 16.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑i ❑ype Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 1 8b.Alternate Facility(or Generator) U.S.EPA ID Number t� Faalitys Phone: tau 18c.Signature of Alternate Facility(or Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardouswaste treatment,disposal,and recycling systems) 2�} 4. 20.Designated Facility Owner or Operator;Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba / ! PnntediTyped Name Signature / ;' Month Day Year EPA Farm 8700-22(Rev�3-04 Previous editions are obsolete. DESIGNATED FACIL{TY TQ GENERATOR