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Please print or type. (Form designed for use on elite (12-phch) typewriter.) Form Approved. OMB No. 2050-0039 EPA Form BIDU-22 (Rev. Mb) Previous editions are obso ete DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) UNIFORM HAZARDOUS 1. Generator ID Number 2 Page 1 of 3 Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST CA2890090002 1 925-4234205 1005870075 JJ K 5 Generator's Name and Mating Address Generator's Site Address (d dffer=nt than mal:ng address) Lawrence Urermore National Laboratory Stte 300 for NNSA Lawrence Livermore National Laboratory Stte 300 for NNSA P 0 Box 806 / L-786 LM ermore CA 94551 corral Hallow Roaa Tracy CA 95376 GeneraWs Phone 923-422-1925 Attn: Shipping 6 Transporter 1 Company Name US EPA ID Number Lawrence Livermore National Laboratory r CA2890012584 7 Transporter 2 Company Name ; r US EPA to Number 5 8 Designated FedGty Name and Site Address US EPA ID Number Lawrence Livermore National Lab for NNSA 7000 East Ave ' l% , lJv ermore CA 945 50 0�VV1L5" Fadi s Phone L 93 9b US DOT Description (Including Proper Sh pping Name, Hazard Class ID Numb < 4`,� } < 11 Tota 12 Unll 13 Waste Codes HM and Packing Group (if any)) a t- t Type Ouanbty WWd a tNA3082, H azardous waste, liquid, n.o.s. (D008), 9. III [ERG 17 1] 132 (Transfer) 1 TT 3 3 Q G -— — Daa6 W 2 2 w i 4 — - - 14 Specia: Handling Instructions and Add tional information Emergency Response Phone 925-4234205 Contact name LLNL Emergency Dispatch 0 Load # LI -NI -14-01, Ship Doc No. S-1 794770 000207300 15 GEN ERATOR'SIOFFEROR'S CERTIFICATION- I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are class fled packaged. marked and labeled/placarded and are in all respects In proper condition br transport accord,ng to applicable International and nation gov4mmeniM regulations If export shipment and I am the Primary Exporter, I certlly that the contents of this consignment conform to the leans of the attached EPAAclknoWedgment of Consent I certify that the waste minimizaW statement identified In 40 CFR 262 27(a) (d I am a large quantity generator) or (b) (H I am a small quantity gene- or) is true GeneratoesJOfferces Printed7Typed Name Si natu" Month Day Year Scott Gil or, Lighelf of NNSA J16 Intemafional Shipments , 11r Import to from Pon Z Ex; rt U S of entry ex t _ Transporter signature (for exports only): Date leaving U S tY 17 Transporter AckwMedgmenl of Receipt of Mateda'a Transporter 1 Pnnted/Typed Name S n Month Day Year CL a ,e- /�7—,W11 07 Q Tran ; e'er 2 PrintedlTyped Name Si, urn Month Day ear r 18 Discrepancy 18a Discrepancy Indication Space Ouaw, ❑ T ❑ Residue ❑ Pariral Rejection yva I ❑Full Rejection Manifest Reference Number _ t8b Alternate Fadrty (or General-.;' US EPA ID Number J U u.. Fadlrtys Plane 0 18c , natureof Altemale FFa^Gty(orGenerator) — Month Day year a z Fn 19 Hazardous Waste Report Ma�agemenl Method Codes ( e. codes for hazardous waste treatmer:t, d sposal, and recycling systems) LLJ 0 1 H J 2-2— 2 3 4 — 20 Designated Facility Owner or Operator Certr:abon of receipt of hazardow materials covered by the mandesl except as noted in hem I Ba Ll PRed/Typed Name Signature Month Day 1,, s�a-T 4, cca i�&m, I ;��JL tit off- I 4 EPA Form BIDU-22 (Rev. Mb) Previous editions are obso ete DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)