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� REUIVED <br /> Please print or type.(Fort designed for use on el to(I 2-pitch)typevmter.) Z 1 I Yi T. <br /> WASTE MANIFEST CA2890090002 9e1 3 e n R nse The na 4,ManlfaslTraekIngNumber <br /> 5 GeneratarsNampandMail!gAddddres 1 925-423r-4Z05 58 JJK <br /> IawrenCe vetrn! IYab",I Laboratory Sits 300 for NNSA Generarors 5ileAddress[rf dHerent than marling address} <br /> P. . Sox 809/ L-79f liv Lawrmr ' Uvrnnorc Nati <br /> oral Hollow Road ry--Sit�396—fur N <br /> Generatoes Phone 925.422-1925 c1 CA 95375 <br /> 6.Trans ATTN:Shipping <br /> , at <br /> porter 1 Company Name <br /> Clears Harbors Environmental Services inc_ tr. EPAIDNumber <br /> 7,Transporter 2Com'paan`yName MA0039322250 <br /> ✓r �• �e fjr f�-�n�ff1 U.5 EPAluriumber <br /> 9 Designated Facility Name and Stla Address "d 17d jD.3 g <br /> Clean Harbors Aragonite, LLC U S.EPA it]Number <br /> 11500 North APtus Road, Aragonite UT 84029 UT0981SS2177 <br /> Facility's Phone. 435-994-81D0 <br /> 92 9b.U S.ROT Description,nduding Proper S''ipping Name,Hazard Class,ID Number, <br /> HM and PackingGroup[danyi, T9 Ca9ta;ners <br /> it.Total 12.Unit <br /> 1. UN3379, Waste,Desensttlzed explosive,liquid,n.o.s.(HMX,RDX , No. Type Quantity WtNVol 13.Waste Codes <br /> 3,1(00T-SP 15448) [ERG US] (00PG354EX-1) Z 0!v! 998 P 0001 F005 <br /> ru <br /> CDR 2 R0.UN3432, Poiyahlonrlated blphenylw solid,9.111(out of Service 3a3 <br /> Date 07/101201S) (ERG 171.) (uOPoon-1) 1 DF 2i K <br /> 3. 751 <br /> 4 <br /> 14 Special Handling Inshuctiorts and Addiha9ai IrsiCrmaG�n <br /> Emergency Response Phone 933-4305 Contact name Load NO. APTL9-02, Ship 0nc No. S-237a WVL Emergenc�r Dispatch. <br /> 5ee attached for container numbers_ 1Zefer�Tce release number UlE0103 on invoice. Used light ballasts. <br /> 15. GE marked <br /> and R'SIDFFEROR'S CERTIFICATION:1 hereby declare Ihal the contents of this consignment are fully and aoatrately described ayOYe by the er s ' <br /> marked and fabeledlpthe contents eta in a!!respects in proper condition far transport according to appfipWe krtema6anal and national governmental regulations.If export sh pment and t am the Prim <br /> Exporter,I certify Ihat the contents of this consignment conform ro the farms of the attached EPAAcknowl Prof tppN' i name,and are rlassi5ed,packaged, <br /> I certify That the waste min mizatioe statement identified in 4Q CFR 262,27{a}(ii I e a a large PAA edgmeni of Consent a <br /> Genetatnrslofferor's Printedfi ry <br /> yped Name � q ty generator}or(b}{it I am a small qu ntity generator store <br /> Scott A- Graham nn behalf of NNSA Signature <br /> P- 16.Intemabonal5hipmant s <br /> Month DaY Year <br /> Z Trans ❑Import to U.S. !(� <br /> Transporter signature[for exports any}: Export from U S _1 <br /> 1st Podotanlrylaxit <br /> TI,TransperterAcknawfed <br /> 9mer'of Receipt at Materials <br /> Dale leaving U S <br /> M T outer 1 PrintedlTyped <br /> O <br /> CL �AJ S' re <br /> / <br /> sparter��yped Name Month Day Year <br /> Signa re <br /> 01 �5 <br /> 18 Discrepancy <br /> Month pay Year <br /> IBa Discrepancy indication Space G <br /> ❑ Quantity �Type ❑Resdue <br /> Partial Rejacton El=ull Rejection <br /> 19b.Allemate Facity{or Generator} fvlanofesl Reference Number. <br /> � Foci itys Phone; U S.EPA iD Number <br /> j 18C.Signature of Attemata Fauiliry(or Generator) <br /> 19 Hazardo-,s Waste Report Me,nagemerI Method Codes(,e.,codes fur hazardous waste treatment,des sal,and i sleuth Day Year <br /> 1 <br /> ! 'O L�ito 2. p' ngsYslems) <br /> HNO 3 <br /> 4 <br /> 20 Designated Faclity Owner or Operator Certification of recerpi of hazardous materas covered by the manifest except as nded ur Ile m 19a <br /> Printedfrme Name <br /> -N h Signature <br /> Farm B700-22(Rev 3,05) Previous edilions are obsolete. Month CV ((Ye e <br /> 1y I t DESIGNATED FACILITY TO <br />