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State of Colifomio—Environmental Protection Agency <br /> Form;Approvad OA*fi4 b-0039(Expires 9.30.94) .See Instructions on back 'age, 6. Department of To Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch)typewriter. Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID.No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST ClAl21819101019 10 10 10 12 91 41 2 1 2 4 of .1 <br /> 3.Generator's Name and Mailing Address <br /> 'Lawenoe Livermore National.Laboratory, Site 300 F <br /> PO Box 808, L-620, Livermore, CA 94551 <br /> Op 4. Generator's phone (510) 422-1825 Aitm Arlene Wilt L-620 <br /> 0 5. Transporter 1 Company Name 6. US EPA ID Number <br /> Evergreen Environmental Services <br /> CAD 8 8 0 8 8 5 7 8 1 <br /> 7. Transporter 2 Company Name 8. US EPA ID Number <br /> 4 <br /> Co 2 <br /> V <br /> Q 9. Designated Facility Name and Site Address 10. US EPA ID Number <br /> W Evergreen Oil,Inc <br /> 6880 Smith Avenue <br /> Newark,CA 94560 C q ® 9 9 0 8 8 7 4 1 8 <br /> C' q <br /> U 12. Containers 13. Total 14. Unit <br /> Z 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. T Quantity Wt/Voi <br /> :V ~ Combustible Liquid n.o.s.,NA1993, III <br /> 7� G (diesel fuel) 0 0 1 T T / G <br /> o E 0 <br /> 00 N b. <br /> 0.0 E <br /> v R <br /> a A <br /> a T C. <br /> 0 <br /> R <br /> W <br /> I.- a. <br /> Z <br /> W <br /> U <br /> W <br /> tq <br /> Z <br /> O <br /> 0- <br /> W W <br /> W <br /> J <br /> Q <br /> Z <br /> O 15. Special Handling Instructions and Additional Information <br /> P Wear Protective Clothing When Handling. EMERGENCY CONTACT. M.N. Hayes, (510) 447-6880 <br /> Z LLNL ShipDoc Number. S- <br /> _IJ4J41 <br /> = These materials are NOT radioactively contaminated. <br /> J 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br /> —' packed,marked,and labeled,and are in all res m proper condition for transport b highway according to applicable federal,state and international laws. <br /> Q P P�� P P Po Y 9 Y n9 PP <br /> V <br /> If I am a large quantity generator, I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> —' economically practicable and that 1 have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> Uthreat to human health and the environment;OR,if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br /> ix waste management method that is available to me and that I can afford. <br /> O Printed/Typed Name Signature Month Day Year <br /> r Richard B.Loden on behalf of LLNL eo# <br /> U <br /> Z e 17. Transporter 1 Acknowledgement of Receipt of Materials i <br /> oN Printed/Typed Name Signatur Month Day or <br /> P / <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> Lu T Printed/Typed Name SignatureMonth Day Year <br /> LL E <br /> O t: <br /> N19. Discrepancy Indication Space <br /> t� <br /> A <br /> Z d <br /> 1 <br /> I 20. Facility Owner or Operator Certification of receipt of hazardous materials covered Wthis m nifes exce t as bated in Item 19. <br /> T Printe Ty Name Signature Month Day Year <br /> Y j <br /> DO NOT WRITE OW THISIN <br /> Yellow: TSDF SE DE.S THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DISC 8022A (7/92) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />