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Please print or type. (Form designed for use on elite (12 -pitch) typewrter.) Form ADDroved. OMB No. 2050-0039 tPAtormtf7uu-L1(Nev.3-Ub) rrevtousembonsare obsolete. D; ;I(;;IA1FD 1=/1 ,11_iTl' 10 DESTINAT10N STATE_ (IF REQUIRED) UNIFORM HAZARDOUS 1. Generator to Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST CA2890090002 2 925-4231205 p 05870341 JJK 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) LavrenCe Livermore National Laboratory Site 303 f,3r PIPISA Laorence U,)ennore National Labortorj Site 300 for bINSA, P.O. Box 8081 L-786 corral nonotiv R>,ao Uvernlore CA 94551 Tracy CA %37E; Generators Phone: 923-422-1923 :Lttn: S!r%.LPPiftq 6. Transporter 1 Company Name�, ,� U.S. EPA (D Number Clean Harbors Ermlronmerltal Services Inc. �'y. fVIA131039322250 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number Clean Harbors of San Jose. LLC 1021 Berryessa Road ENVIRONMENTAL _ San Jose CA 95133 HEALTH DEPARTMENT FBcilft es Phone; ga, 9b. U.S. DOT Desolption (Including Proper Shipping Name, Hazard Class, 0 Number, 10. Contalners11. Total 12. Unit Hyl end Packing Group (If any)) Quantity Wt.Nol. 13. Waste Codes No. Type 01'UN 1814, Waste, Potassium hydroxide, solution, 8, II [ERG 154] 122 (DOP0015-1) 1 DF 76 P naaz 2UN3288, Waste, Corrosive liquid, basic, inorganic, n.o.s., 8, III (Lab 122 pack) [ERG 154] (DOP0114-1) 2 DF 287 P Haas 3Non-RCRA hazardous waste, liquid (USED OIL) (DOP0089-10 221 1 1321 4�0 P 4.Non-RCRA hazardous waste, liquid (poly alkysiloxane solution) 331 (DOP0010-1) i DF 411 P 14. Special Handling Instructions and Additional Infonmaton Emergency Response Phone 925423-4205 Contact name LW L Emergency Oispatch.0 Load # SJ10-08, Ship Doc No. S-202798, Reference release number LSJO385 on invoice. See attached for container numbers. 15. GENERATOR'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 classified, packaged, marked and fabeledlplacarded, and are in all respects in proper condition for transport according to applicable International and national governmental 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. I certify, that the waste minimization 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 tryp GeneratoeslOfferors Printed/Typed Name Signalure Month Day Year s �' C► 1 (0 F- 16. International Shipments ❑ import to U.S. ❑ Export from U.S. Pod of entrylexil: Z Transporter signature (for exports only): Dale leaving U.S.: LU 17. Transporter Acknowledgment of Receipt of Materials Trans r 1 Prttnt�yped Name `/ , Sig re Mon/th Day Ypar IL rn x l 1 Z Tran -Wer 2 Prirt Name Sig ure Month Day Year ce 18. Discrepancy 18a. Disoepancy Indication Space ❑ Quantity El T' ype ❑ Residue ❑Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Allemate Facility (or Generator) U.S. EPA ID Number 7 U LL Facility s Phone: W 18c. Signature of Altemate Facility (or Generator) Month Day Year Q Z y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) OW 1. 2. 3. 4. 20. Designated Facility Owner or Operator. Cedifcation of receipt of hazardous materials covered by the manifest except as noted in Item 18a PantedlTyped Name Signature Month Day Year tPAtormtf7uu-L1(Nev.3-Ub) rrevtousembonsare obsolete. D; ;I(;;IA1FD 1=/1 ,11_iTl' 10 DESTINAT10N STATE_ (IF REQUIRED)