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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTEMANIFEST CA2890090002 1 192S-423-1205005870992 JJK 5.Generator's Name and Mailing Address Generator's$ite Address(if different than mailing address) Lawnirn= Livemmre National Laboratory Srtr 3DD for NNSA Lawrrencr Lr,vrmcrre National LaburaL^ry Site 3N for NNSA P.O . BCY 9021 L--?96 lsvrm-zrr CA 94551 corral Nvifah Road 'rrmcf C—A 95376 Generator's Phone: 925-322-192S A I-rtj-Sls oolr-a fi,Transporter 1 Company Name U.S.EPA ID Number Clean Harbors Erl-*DTlmental Services Ir1c. MAD039322'250 7.Transporter 2 Company Name U S.EPA ID Number 8,Designated Facility Name and Site Address U S.EPA ID Number Clean Harbors Bsttnrwdtraw . Lit CAD98067S276 25DO Wrct Lekern Road . Buttonwillow CA 93206 Facility's Phone' 661-762-6200 9a 9b.U S DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 Conainers 11.Tola 12 Urit Hht and Packing Group(d any)) 13.Waste Codes No Type Quantity Wl.-'rd. 0 1. RCL NA22U usbestoi.9 ill EERG 171 t~1 {GCO22DE-1) f--M 20 � 15l z c� 4 14 Special Handing Instructions and Additional Information Emergency Response Phone 925—423—42D5 Contact name l-LNL Err ergens'j GtspatCh Load ETW19-47 Ship ax No. ;•-241?62 , R=rer,fnC* release number L X t t]_rn_(9 ,3 on invorte =30M59. Bin No crrii;'20505 . SJV-4PM- aaM Enterjanse Way, Modesto CA 95356,sc*, ,�qj 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this cansd nment are fully and accurately described above by the proper shipping name,and are dassified,packaged marked and labeled,'ptacarded,and are in all respects in proper condition for transport according to applicable International and national governmental regulations.It export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknoWedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 26227(a)(it I am a large quanMy generaar)or(b)(if I am a small quantity generator)is true. GeneratoesOfferors PnniedlTyped Name signature Month Day Year Scott A. Graham on behalf of NNSA 1 16.Intematonal Shipments x ❑Import to U.S. ❑Export from U.S- Part of entylexit: - Transporter signature(for exports only); Date leaving U S: 17.Transporter Adwidedgment of Receipt of Materials Transporter 1 PnntedfTypecl ame .' Signature Montt Day Year, Q Transporter 2 Printedrryped Name — Signature Month Day Y r tr r- 18.Discrepancy 18a Discrepancy Indication Space ❑ tuantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Nur.ber 18b Atemate Facility(or Generator) US EPA ID Number J 'v W Faaftjs Phone: W 18c Signature of Alternate Facility(or Generator) Month Day Year a z1 19 Haxsrdous Waste Report Management Method Codes(i.e.codes for hazardous waste treatment,disposal,and recycling systems) a 20 Designated Faai:ty Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pnntkayped Name Signature 1/.J Month Day Year EPA Farm 8700-22(Rev.3-05) Previous editions are obsolete :' DESIGNATED FACILITY TO GENERATOR