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<br />Pleasib print or type. (Form designed for use on elite i12 -Ditch tvoewrite?.) U!z3/ t c,,,,.. A,...M,,.,A nAxo .r., '1-
<br />EPA Fain 8700- (Rev 3-05) Previous editions QSobsolete I DESIGN I&ED FACILITY Td GENERATOR
<br />UNIFORM HAZARDOUS
<br />1 Generator ID Number
<br />2. Page 1 of
<br />T3 Emergency Rexonse Phone
<br />4. Manifost Tracking Number
<br />WASTE MANIFEST
<br />CA2890090002
<br />925-d23-420.5
<br />1005870090 JJ K
<br />5 Generator's Name and Mailing Address Generators Site Address (C different than matting address)
<br />Lawrence Llrermnre National Laboratory Site WO for NNSA
<br />P.0 Box 808 / L-786 Laarence 1.1yermore Nattonai Labovoq S",r '' for NNSA,
<br />Livermore CA9A551 Condi H0IIOW Road
<br />Tracy CA 953-6
<br />Generators Phone 523-422-1929 Attn: snippinq
<br />M IM M
<br />6 Transporter 1 Company Name
<br />14
<br />R
<br />US EPA to Number
<br />Clean Harbors Environmental Sen!ces Inc.
<br />V-
<br />MA0039322260
<br />7 Transporter 2 Company Name US EPA ID Number
<br />O 14
<br />E Designated Facility Name and Site Address U S EPA ID Number
<br />Clean Harbors of San Joce, LLC
<br />1021 Berryessa Road ENVIRONMENTAL HEALTH
<br />San !ose CA95�33 CAR054R+�3�0
<br />Fai*y'sPhone 40e_451_gp00 DEPARTMENT
<br />ga
<br />9b U S DOT Description (including Proper Shpping Name, Hazard Gass, ID Number,
<br />10. Containers
<br />1t Ta,:
<br />12 Unit
<br />13 Waste Codes
<br />No
<br />I Type
<br />HM
<br />and Packing Group (f any))
<br />Quant! r
<br />WuV6
<br />a
<br />1 UN 1223, Kerosene, 3.111 [ERG 126] (DOP00%1 }
<br />331
<br />30
<br />P
<br />—
<br />_ _ _
<br />w
<br />w
<br />UN 1893, Mae, Flammable liquids, -ti o.s (acetone, mettryl ethyl
<br />343
<br />ED)d
<br />ketone;, 3,11 [ERG 128] (DOP0054A-1)
<br />i
<br />t"
<br />32
<br />P
<br />_
<br />naafi
<br />3'. )' ' +30. W2dste Suffuric acid 8 II (ERG 1371 (DOP0401-1)
<br />----
<br />791
<br />3
<br />DE'
<br />64
<br />P
<br />rcc:
<br />4 NA3077, Hazardous waste, solid, n.o.s. (121008), 9, III (FRG 1711
<br />lel
<br />(DOP013148-1)
<br />1
<br />DF,
<br />s
<br />P_
<br />Do03
<br />14` Special Handling Inshetions and Additional Infonrnation
<br />Emergency Response Phone 92&423-4205 CUnt;act name LI NL Emernen y Disp3,-dh
<br />Ss1APCD - 4800 Enterprise Way, Modesto, CA 95356 Load K _ SG, Ship Doc No
<br />S-182034, Reference release nutyber L-SJO079 on invoice See Attachment for container nulTlbe
<br />15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and acaim" described above by the proper shipping name, a reclassified, packaged,
<br />marked and labelodlplacarded, and are in all respects In proper condition for transport according to applicable international and national governmental regulations If export shp. nt and i am tha Pnmary
<br />Exporter. I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent
<br />I certify, that the waste minimization statement identified in 40 CFR 262 27(a) (if I am a large quantity ge ) or (b) Pf I am;4111 q ; ty generator) is true
<br />Generators/Offeroes Printedrryped Name fig Month Day Ycar
<br />Seen Game on k --half of NNSA
<br />-..r
<br />F-
<br />16 International Shipments
<br />❑ Import to U S ❑ Export horn U S Portof entry exit
<br />Transporter signature (for exports only) ate leaving U S
<br />IX
<br />17 Transporter Acknowledgment of Receipt of Materials
<br />WTransporter
<br />1 Pnnted7Typed Name Signature Month Day Year
<br />I
<br />O
<br />d /
<br />a
<br />QTransporter
<br />2Pnnted/rypedName Signature M,,nth Day Year
<br />18 Discrepancy
<br />18a Discrepancy Indcation Spar n O, antty ❑ Type ❑ Residue ❑ Partial Rejection ❑ FUl Rejection
<br />Manifest Reference Number
<br />~
<br />18b Alternate Facility (or Generator) US EPA ID Number
<br />J
<br />U
<br />tai.
<br />Fadt/s Phone
<br />18c Signature of Altemate Facility (or Generator)
<br />Month Day Year
<br />z
<br />LDa
<br />19 Hazardous Waste Report Management Method Codes ( e, codes for hazardous waste treatment, disposal, and recycling systems)
<br />0
<br />1
<br />Vill,//
<br />2
<br />3 9070
<br />4
<br />20 Designated Facility Owner or Operator Certification of receipt of KAa6us materials covered by the manifest except as noted in Item 18a
<br />FT-Aedllryped Name Sig lure Month ay YearV- Int ;IiAa ��t&N AA&
<br />IN
<br />EPA Fain 8700- (Rev 3-05) Previous editions QSobsolete I DESIGN I&ED FACILITY Td GENERATOR
<br />
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