COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

Please print or type i7omn designed for use on elite(1 2-pitch)typewriter.) Form Approved OMB No 205OM39 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CA289001.2584 1 925-423-4205 100587 016 JJ K 5.Generators Name and Mailing Address Generators Site Address(if dalerent than mailing address Lawrencm Livwn torn �Vatono]Lcboratory for NNSA7000EattAve-- La wren=Liuecrrcre Natr ral Loborivtar/ arNNSA?j0 F astAwc L 796I.rvrfrrcrra CA 9455D Uvrermore CA 94550 GeneraloesPhone: 925-422-1925 ATTN:ShWptrtg 6.Transporter 1 Company Name U.S EPA ID Number Lawrence Livermore National Laboratory CAMWUSHw 7.Transponer 2 Company Name U S.EPA ID Number 8,Designated Facility Name and Site Address US EPA ID Number Lzwrcnze Livafmore Natorral Lsbcratery,Site 300Cvr-al Hollow Floati T=f CA 35376 ;�A2890090002 Far:Oys Phone: $25-422-1925 9a, 9b,U,S DOT Description(incEuding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Tota, 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt No$ 1.UND475, Was*e,Substances,e*osrve,n o.s.(PETN,ROK), 1.1GD003 (DOT-SP 1s448) (ERG 1121 E►NSF 7rz z z W 3 14 Speoal Handling Instructions and Additional Information Emergency Response Photo S25-473.4205 Corract name LLNL Emergency CrrsParin F-Oaa A EWSf L9-Et3, ship F3a mo t-24m - 54-e attach*d for containernumbefs. r5. fiilEN19RATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this wnsignmenl are fully and aecurately described above by the proper shipp,ng name and are classified packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international 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 EPAAcknowledgmenl of Consent. I certify that the waste minimization statement identified in 40 CFR 262-27(a)(if I am a large quantity generator)or(b)(if I am a small quantity ge rator)is true GeneralorslOfferors Printedlryped Name Signal A Month Day Year 5cc nt A. Graham on behatf of NNSA ,h OS 01 1 1 q 16.Intemationai Shipments-� J Z Elorn Import to U.S. ❑Export h U 5 Port of entrylexit Transporter signature(for exports only)- Date leaving U S 17 Transporter Acknowledgment of Receipt of Materials Transporter i Pnntedffyped Name Signature } Month Day Year off. a Transporter 2 Pnntedl;yped Name 5ignahlr Month Day Year H 10,Discrepancy 18a,Discrepancy Indication Space ❑ Quantty ❑Type ❑Residue ❑Partial Rejection El p FuI.Re c Manifest Reference Number. 1 Br:Alternate Facility(or Generator) x U.S EPA ID Number U Facility's Phone: W 18c.Signature ofAltemate Facility(or Generator) t1or.7. Da} }'ear a z 19.Hazardous Waste Report Management Method Codes(i.e,codes for hazardous waste treatment disposal,and recyding systems) 0 1. 2 3 4 20 Designated Facility avner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted'n Item 18a PrintediTyped Name Signature Month Day Year EPA Form 6700.22(Rev.3-05) Previous editions are obsolete DESIGNATED FACILITY TO GENERATOR