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r° Please print or tv0e. (Form desloned for use on elile (12•oitch) tvoewriter.) P- A munrl MAP Mn ')nrn_Win EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST CA2890090002 7 925-423- 1205 1005870331 JJ K 5. Generator's Name and Mailing Address Generator's Site Address (if different than ma;Ing address) Lawrence Llnermore National Laooratar; Site 300 for NNSA Lawrence Uvermore National Laboratonj site 3GKJ for ftIf'kISA P.O. Box 808! L-786 Corral Hollow Roaa Livermore CA 94551 Generators Phone: 923-422-1923 Attl ?illn in TfaCgGA S'- 6. Transporter 1 Company Name U W ? U.S. EPA ID Number Clean Harbors Environmental Servlce6 Inc. MAD0339322260 7. Transporter 2 Company Noma JAN 14 2016 U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number Clean Harbors of San Jose, LLC ENVIRONMENTAL 1021 Beril Road HEALTH DEPARTMENT San Jose CA 95133 CAD059494370 Facilit es Phone: 98, 9b. U.S. DOT Descdpllon (Inclking Proper Shlpping Name, Hazard Class, ID Number, 1o. Contalners 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group P any)) Quantty Wtivol. 0 1';0, UN1219, Waste, Isopropanol, 3, It (RQ 0001) [ERG 129] Lq@7 �lz (DOP0054-1) 1 P Daal 0 !. is , 2-UN1203, Waste, Gasoline, 3,11 [ERG 1281 (DOP0054-1) 214 I DN 12 P Daal 3 -UN 1993. Waste, Flammable liquids, mo.s. (acetone, ethyl acetate), 3, II 34 (ERG 1281 (DOP0054-1) 1. nM 49 P -- --- Deal 4 UN1993, Waste, Flammable liquids, n.o.s., 3, II (lab pack) [ERG 128] 331 X1 (DOP0116-1) 1 OF 5 P ---- - D0a1 14. Special Handling Instructions and Additional Information Emergency Response Phone 925-423-4205 Contact name LLNL Emergency Disp atch.❑ Load # SJ15-24, Ship Doc No. S-202153, Reference release number LSJ0375 on invoice. See attached for container numbers. 15. GENERATOR'StOFFEROR'S CERTIFICATION: I hereby declare that the contents of Bus consignment are fully and accurately described above by the proper shipping name, and are classi`ed, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to app,iraNe intemaConal and national govemmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent certify that the waste minimizallon statement identified In 40 CFR 262.27(a) (If I am a large quantity generator) or (b) (if I am a small quantity generator) Is true. GeneratorslOfferors Pdntedrryped Name Month Day Year a 1 /0 i S t 16. International Shlpments ❑ Import to U.S. El bpm hem U.S. Port of entrylexit Transporter signature (for exports only). Dale leaving U.S.: 0C 17. Transporter Acknowledgment of Receipt of Materials Trans er 1 Pr nteyped Name S gna Month Day Year 0. ZTr nspoder 2 Printed/Typed Name ureonth Day Year 16. Discrepancy 18a. Discrepancy Indicalfon Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection Dull Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number U Faciliitys Phone: 16c. Signature of Alternate Facility (or Generator) Month Day Year N19, Hazardous Waste Report Management Method Codes (i.e., cafes for hazardous waste treatment, disposal, and recycling systems) 0 1. 2. 3. 4. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 188 Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete.