COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12•pita)typewriter) Form Approved,OMB No 2050-0039 UNIFORM HAZARDOUS I Generator ID Number 2,Page 1 of 3.Emergency Response Phone Manliest Tracking Number WASTE MANIFEST CA 70058 2S40012SS4 } 925-423_020S f 0 AOJ 8 9 JJK 5.Generator's Name and Mailing Address Generator's S;tie Address(if d5erent than mailing address) Lawrence livmnore National Labera"- (or'.'i;A Lo-x-enrr Lrvwmore National Labornmry for#INSA 7000 Fast Ave-L-M,L.vr:rmcre C.A 945SO 7DCta Last Ave,isvernrv,-e CA 9455D GeneratoesPhDne:925-422-1: 25 ATnj Shrrsn;-a 6,Transporter 1 Company Name U.S.EPA ID Number Lawrence Livermore National Laboratory CA2890012S9d 7 Transporter 2 Company Name U S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number Lawrercr Livermore National Laboratory, S-te 300 Lcirral IJa'!ow Road Tracy CA 9537E Facility's Phone , -. , jr ga 9b.U.S.DOT Description Including Proper Shipping Name,Hazard Class,ID Number, 10.CDntairers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(it anyl) No Type Quantity wi Nol. 0 1.UND475, Waste,Substances.Rxrt_---srvre n as i(PETN.ADX a P (DOT-39 L5,M) [ERG IUJ EWSF s 2 W C7 3 4 14,Specal Handling Instructions and Additional Information Errlt►rg>Mcr ltesptzn;t Phone 925 ii33A2?15 ContCt name LLNt Err'esger>cy #sir Fctti.l❑a f 1�r F 19-02. 3h C}a Rio, L• (la; C::+iltdlri�r� �i� C�7iJ3OFi�7Q. Ci�3�,fi�. ��3rJ63LO 15 GENERATORVOFFEROR'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 labeled,'p acarded,and are in all respects in proper condition for transport according to appi cable intemationaf and national governmental regulations.If export shipment and I am the Primary Exporter.I certify that the contents of this consignment conform to the terms of the attached EPAAckno-Aiedgmenl of Consent. I certify that the waste minimization statement identified in 40 CFR 262 Via)(d I am a large quantity generator)or(b)(if I am a smal quantity generator)!,true. Generator'sf0fferor•s PnntedfTyped Name S gnature Month Day Year Scott A. Graham or,behatt of N NSA l03 n7 —J 16.InternationalShipments 1- ❑Import to US. ❑Export from U S. Port of entry.'exit Z Transporter t si naure(for exports only): t 9 Po Y) Date leaving U.S.. 17.Transporter Acka iedgment of Receipt of Materials r� Transporter t PrintedlTypejName Sign ' Month flay Year CL zQ Transp(Wer2Printed'T}pedName "5igrs lute' f Month Day Year fY C.✓ 16.Discrepancy 18a.Discrepancy Indication Space ype ❑ i ElFutl Rejection Quantify ❑T ❑Residue Partial Rejection Manifest Reference Number: 18b,Qlarnate Faolity(or Generator) U S.EPA 10 Number V Fa36�'s Phone LU 18c.Signature of Alternate Facility(tor Generator) Month Day Year a a 19.Haardcus waste Report Management Method Codes Le.,codes for hazardous waste treatment,disposal,and r_orJing systems) G i r rr 2 3. 4. - '�/ 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered try the manifest except as noted in Item 19a Prigtedlfyped Name l Signature s Month Day Year EPA Form 5700.22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY