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Please orint or lupe. (Form designed for use on elite 112 -Ditch) typewriter.)
<br />Form Annroved. OMB No. 2050-0039
<br />EPA Form 8700-22A (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)
<br />UNIFORM HAZARDOUS WASTE MANIFEST
<br />ID Number
<br />22. Page
<br />23. Manlfast Tracking Number
<br />(Conllnuat►on Sheet)
<br />121.13,nerater
<br />0690090002
<br />3
<br />0055870331 .JJK
<br />24. Generators Name Lawrence Ugernl0re National Laboratory Site 300 for 1\10 I
<br />P.O. Box M I L-785
<br />Lnr ermore CA 94551 2016
<br />25. Transporter Company Name U.S. EPA ID Number
<br />28. Transporter Company Name P U.S. EPA ID Number
<br />HEALTH GE. ARTMEN
<br />27a.
<br />27b. U.S. DOT Description (including Proper Shtpping Name, Hazard Class, ID Number,
<br />28. Containers
<br />29. Total
<br />30. Unit
<br />Waste Codes
<br />No.
<br />Type
<br />HM
<br />and Packing �p (d any))
<br />Quantity
<br />WL/Vol.31.
<br />15. NA3077, Hazardous waste, solid, n.o.s. (DO08), 9,111 [ERG 171]
<br />(CrG�PQQ3B-1)
<br />181
<br />D008
<br />2
<br />ON
<br />158
<br />P
<br />16. NA3077, Hazardouswaste, solid, n.o.s. (0008), 9, ill [ERG 171]
<br />(DOP0036-1)
<br />i
<br />OF
<br />9
<br />P
<br />181
<br />Doos
<br />17. NA3077, Hazardouswaste, solid, n.o.s., 9,111 (lab pack) [ERG
<br />331
<br />171] (DOP0113-1)
<br />i
<br />OF
<br />7
<br />P
<br />D035
<br />v
<br />18. RQ, NA3077, Hazardouswaste, solid, n.o.s. (D011), 9, III (RQ
<br />lsl
<br />D011) (ERG 1711 (DOP003@-1)
<br />1
<br />DM
<br />1e5
<br />P
<br />Doil
<br />w
<br />19. RQ, NA3082, Hazardous waste, liquid, n.o.s. (DO10, DOI 1). 9,
<br />541
<br />III (RQ 0011) [ERG 1711 (DOP0013-1)
<br />2
<br />ON
<br />1022
<br />P
<br />D010
<br />20. RQ, NA3082, Hazardous waste, liquid, n.o.s. (0011), 9, III (RQ
<br />541
<br />0011)[ERG 171](DOP0013-1)
<br />s
<br />JDN
<br />2407
<br />P
<br />Doll
<br />21. RQ, NA3092, Hazardouswaste, liquid, n.o.s. (D011), 9, III (RQ
<br />541
<br />0011) [ERG 171] (DOP0013-1)
<br />i
<br />ON
<br />489
<br />P
<br />Dolo
<br />/ lMhr
<br />r/41115-
<br />xi
<br />N. Non P.CRA hazardous waste, liquid (dilute sulfamic sad
<br />134
<br />solution) (DOP0009-1)
<br />1
<br />OF
<br />100
<br />P
<br />32. Special Handling instructions end Additional information
<br />33. Transporter_AcknoWedgmentof Recelptof Materials
<br />Printed/Typed Name S!gnaturo Month Day Yalu
<br />oc
<br />0
<br />a
<br />34. Transporter AcknoWed ment of Receipt of Materials
<br />Prtnted/Typed Name Signature Month Day Year
<br />t—
<br />35. Discrepancy
<br />J
<br />U
<br />LL
<br />0
<br />Q36.
<br />20
<br />Hazardous Waste Report Management MAW Codes Q.o., codes for hazardous waste hnatmenl, disposal, and recycling systems)
<br />rn
<br />W
<br />O
<br />EPA Form 8700-22A (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)
<br />
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