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State of Colifomio—Environmental Protection Agency <br /> Form Ap o.2050-0039(Expires 9-30-94) _, She IflstRictions on back o ge 6. art eM of Toxic 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 /> i. <br /> WASTE MANIFEST <br /> ICIA121819101019101010121 91 .41 2 3 6 of 1 <br /> 3. Generators Name and Mailing Address <br /> in <br /> ce Livermore National Laboratory, Site 300 <br /> 7WO East Avenue, Uveffnom,CA 9z; <br /> C4. <br /> 4. Generators Phone (514) 422-1928 Atte:A.Wilt L-620 <br /> 00 <br /> 5. Transporter 1 Company Name 6. US EPA ID Number <br /> 0o Erickson* Inc <br /> CAD 0 0 9 4 6 8 3 9 2 <br /> �+ 7. Transporter 2 Company Name 8. US EPA ID Number <br /> ` .Q <br /> Q 9. Designated Facility Name and Site Address 10: US EPA ID Number <br /> O ERICKSON INC. <br /> r-i255 Parr Blvd., Richmond, CA 84801 <br /> .0 C A ® 0 0 9 4 8 6 3 8 2 <br /> V V 12. Containers 13. Total 14. Unit <br /> 00 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> Z No. Type Quantity Wt/Vol.'. <br /> S' a. <br /> N 3 Non RCRA Hazardous Waste,Solid (Empty Containers Last Containing <br /> .. G Diesel Fuel)(with associated piping) 0 0 1 TP 0121010P P <br /> N E <br /> -N. b. <br /> 0o E <br /> c4 R <br /> o A <br /> T C. <br /> 00g. O <br /> oc R <br /> W <br /> ~ d <br /> Z <br /> W <br /> U <br /> W <br /> c� <br /> Z <br /> 0 <br /> a <br /> to <br /> W <br /> tY <br /> J <br /> Q <br /> Q15. Special Handling Instructions and Additional Information <br /> ►- EMERGENCY CONTACT: (510) 447-6880 <br /> Z Wear protective doll-ing while handling These materials are NOT radioactively contaminated. <br /> LU HWM Requisition Number H 135774 T'RNK $71101IU1 <br /> 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 /> –' <br /> packed,marked,and labeled,and are in oil res m proper condition for transport b highway according to applicable federal,state and international laws. <br /> Q P P�� P Pe sP Y 9 �' n9 PP <br /> tJ t <br /> If 1 am a large quantity generator, I certify,that I 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 I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> Nthreat to human health and the environment;OR, 0 1 am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best <br /> waste management method that is available to me and that I can afford. <br /> 0 Printed/Typed Name Signature Month ^Day Year <br /> Riohatd 9 Lodon on bohalf of LLNL d 7 R G <br /> U <br /> Z T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> W n Printed/Typed N e/ Signature Month Day1 Year <br /> C-1 <br /> s //�( J Q e r G7 <br /> P <br /> 0 18. Transporter 2 Acknow dement of Recei t of Materials OF <br /> W T Printed/Typed Name Signature Month Day Year <br /> UL E <br /> N19. Discrepancy Indication Space <br /> Q F <br /> Z A <br /> C q4 <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Trated/Typed Name Sig re Day Year <br /> Y <br /> DO NOT WRITE,BELOW THIS LINE. <br /> Yellow. : .TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (7/92) (Generators:who submit hazardous waste for:transport.oufof-state, <br /> EPA 8700-22 =_ produce completed copy of this copy and send.to,DTSC within 30 days.) <br />