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<br />-•••• •••• �,,... - 1 „c.wuacwuuna... —wrcm. Ii1:;.1r'il`11CI[-11 i ACN-1T-`11,0 DC-S'FINATI014 SIiaTE (IF RCOUIRED)
<br />-..."- . l-orm Approved. OM8 No. 2050-0039
<br />UNIFORM HAZARDOUS 1 Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4, Manifest Tracking Number
<br />WASTE MANIFEST CA2890090002 6 9G5 -ti 2S-' 12x15 1005870461 JJK
<br />5. aviretors Name and Mailing Address Generator's Site Address (f different than mailing address)
<br />L..:rrence uvertrere idst!enal t?b�;atnrr; '-1t'= 340 112rMf�l�s.
<br />P 0 807.8081 L -73r, a,,;rer c2 Ltc err'rjr _ N211010 L3CO3otGrj Glt? 3GC ,ar NNSA
<br />114 enr,: ra L ; 9 5�1 Corral rlotlg�d
<br />Generator's Phone: r 3C t" v
<br />-__-a22-i5 _ crri: _l�ipoia�
<br />6. Transporter 1 Company Name y ea = "- ' U.S. EPA ID Number
<br />Clean HZcry Et;11Ir0r vna-,,}'.2l Sef'.'ICc:S if!:' MrD09S22250
<br />—Company
<br />7. Transporter 2 Name LU I I U.S. EPA ID Number
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<br />6. Deslgnatad Fedlity Name and Site Address S. EPA ID Number
<br />Clean H2rttnr8 Qt 531 JJBa. Li- t� VIR�NMENTAL HEALTP:
<br />1021 C! G3i, T
<br />IVIENT
<br />!ose c.,s:� ,; DEPAI� I a A%Uv�9g� eC
<br />Facility's Phone: -.. a i -q ,
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<br />9b. U.S. DOT Description (fncluding Proper Shlpping Name, Hazard Class, ID Number,
<br />10. Contalners
<br />11. Total
<br />12. Unit
<br />HM
<br />and Packing Group (if any))
<br />Quantity
<br />WtNol.
<br />13. Waste Codes
<br />Na.
<br />Type
<br />"UH 1203, rwastia. iia oline, 3, II (ERG 1281 +00PG054-11
<br />c
<br />214
<br />1
<br />1%12
<br />78
<br />P
<br />w
<br />7J :1
<br />1993, VJasre. Flammable liquids, c.c.s., 3, 11 (LaC pack) fc—PG 123CD ]
<br />224
<br />DG01
<br />3 UN1325, Fiarnmab!e solids, organic, n.o.s- 4.1. 11 (Lab pack) [EPO 133]
<br />„1
<br />I'DOR117-1)
<br />-_.. -
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<br />E7'c"
<br />38
<br />a
<br />4'UN2039,'Waster, Metal povvders, flarnrnable, n.o.s., 4.1, li (Lab pa6K)
<br />I
<br />FERG 1701([:'0P01.17-1 }
<br />121
<br />2
<br />IbiE
<br />34
<br />PX
<br />°cas
<br />-
<br />14. Special Handling Instructions and Additional Information
<br />Emergency Response Phone 925-423-4205 Contact name LLNL Emergency Dispatch. ❑
<br />Load * SJ17-12, Ship GOC Nl,..;. S-2.10128. Reference releas:= nurnber LS1 058q on irivois-e.
<br />See attaohed for container nun -deers.
<br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged,
<br />marked and labeled/placarded, and are in all respects in proper cored6on for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary
<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 generator) or (b) (if I am a small quantity generator) is true.
<br />Generators108erors Printedlryped Name Signature - Month Day Year
<br />_j
<br />F-
<br />16. International Shipments
<br />❑ Import to U.S. ❑ Export from U.S. Port of entrylexil:
<br />Z
<br />Transporter signature (for exports only): Date leaving U.S.:
<br />W
<br />17. Transporter AdToWedqment of Receipt of Materials f
<br />�
<br />Transporter 1 Printedgyped Nam Si tune /
<br />/ ` � — Month Day Year
<br />X/
<br />CL
<br />QTransporter
<br />2 Prinle frypod atne "na re Month Day Year
<br />18. Discrepancy
<br />18a. Discrepancy Indication Space ❑ Quantity ❑ T ❑
<br />ype Residue ❑Partial Rejection ❑Full Rejection
<br />Manifest Reference Number:
<br />181b. Allemate Facility (or Generator)
<br />J
<br />U.S. EPA ID Number
<br />U
<br />tai
<br />Facility's
<br />U0
<br />Phone:
<br />18c Signature of Alternate Facility (or Generator) Month Day Year
<br />a
<br />Z
<br />N[19.Hazardous
<br />Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />C
<br />1'
<br />2
<br />1 1
<br />3.
<br />4.
<br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br />CnA
<br />Printedfiyped Name Signature Month Day Year
<br />C...-.. o
<br />-•••• •••• �,,... - 1 „c.wuacwuuna... —wrcm. Ii1:;.1r'il`11CI[-11 i ACN-1T-`11,0 DC-S'FINATI014 SIiaTE (IF RCOUIRED)
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