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State of Colifomia—Envirpnmemet Protection Agency - �/ _ t <br /> Form Approved o. 040039 fExpires 9.30.94) S@e Ins#}actions on back q age 6. 6?portment of Toxic Substances Cont <br /> Please pnm or type. form desioned for use on elite(12-0ch)typewriter. Sacramento,Califomia <br /> I 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 ( Information in the shaded areas <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFESTis not required by Federal low. <br /> QA 21 81 9I01019101010 2 91 41 2 3 1 7 1 of t <br /> j3. Generator's Name and Alailing Address <br /> OL Lawrence Livermore National Laboratory, Site 300 <br /> N I 7000 East Avenue, Livermore, CA 94550 <br /> N 4. Generator's Phone (510) 422_1925 Attn: A. Wilt L-620 <br /> m <br /> O 5. Transporter 1 Company Nome 6. US EPA ID Number <br /> Erickson, Inc <br /> �CAD00948813912 <br /> —J+I 7. Transporter 2 Company Name 8. US EPA ID Number <br /> QI <br /> UI <br /> 9. Designated Facility Nome and Site Address 10. US EPA ID Number <br /> ERICKSON INC. <br /> -.D L- 255 Parr Blvd., Richmond, CA 94801 <br /> !C1.� CIAD01084815 31912 <br /> My Z I 11. US DOT Description(including Proper g p Shipping Nome,Hazard Class,and ID Number) l2. Containers ; 13. Total 14. Unit <br /> .IV <br /> 11 tt No. T Quantity Wt/Vol <br /> 3 I Non RCRA Hazardous Waste,Sand (Empty Containers Last Containing ! � <br /> M E Diesel Fuel)(With associated piping) 01 G 1' T,P ! Oi 2 <br /> co N 1 <br /> E <br /> fVI R <br /> �I A <br /> 0 <br /> o �. <br /> C? O <br /> cei R 1 <br /> WI <br /> WI d <br /> W <br /> V) <br /> Z <br /> O <br /> to <br /> W <br /> �I <br /> 0 Q� <br /> 15. Special Handling Instructions and Additional Information R.6. Q E <br /> t=I EMERGENCY CONTACT: (510) 447-8880`1 IT Job# 152298 <br /> Q I <br /> Z; Wear protective clothing while handling These materials are NOT radioactively contaminated. <br /> LU I <br /> HWM Requisition Number H135771 7'i4,t14K g 3YDIV f <br /> J 1 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 /> Q I packed,marked,and labeled,and are in oil respects in proper condition for transport by highway according to applicable federal,state and international laws. <br /> U Z <br /> JIf I am a large quantity generator, I certify that I have a program in pl�ce 20'rtd*uce the volume and toxicity of waste generated to the degree I have determined to be <br /> CL 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 /> threat to human health and the environment;OR,if I am a small quantity generator, I have made o <br /> N q ty g good faith effort to minimize my waste generation and select the be <br /> waste management method that is available to me and that I can afford. <br /> O Printed/Typed Name Signature <br /> Richard B Loden on behalf of LLNL 9 Month �Do ear <br /> U T 17. Transporter 1 Acknowled ement of Receipt of Materials fy. <br /> W R <br /> A Printed/Typed Name Si nater <br /> N 9 Month D Year <br /> s SfI/''I G ve Z '7 a 9 <br /> W P o <br /> g o 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> W <br /> T <br /> Printed/Typed Name Si nature <br /> W e 9 Month Day Year <br /> Q a I <br /> W 19. Discrepancy Indication Space <br /> V) <br /> Q F <br /> U A <br /> I <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19. <br /> T Pr'nt� �! Nome Si <br /> Yre Month Day Year <br /> I � 01712-17q <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A 17/92) (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 />