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Please DmI ct .(Form for use on elite+i2-Grk3rf Ipewgur, Frim Ayprtred Dh'IS No.205M39 <br /> T UNIFORM <br /> tilaNHau O U5 '$9 0 02 1age t of 13 92y 3e o r. Mrs I <br /> WASTE 005870880 JJK <br /> { 5 Ge eratas s Na and 61Ar'irq A�ress Ge cr�L Site Atld qss pr dL'arent flan rrwhg adaess- <br /> L-vrrrrts �vt rmt:rt ,sLarat L-barst_ry 51- 300 for ri'JSA E wrr-is ��rrrr+nre NaOt±^r Lasa^ato . 5 sr 10 (=- 06SLA <br /> F.0 Baa E=0e? 1-?96 L?err:rr, CA 9455= _.rrn' 11o,'as. Acad. Tr=o CA 951?6 <br /> Gereratct'sPhD".915 411 1525 Ar : ;5^.CP na <br /> 6 Trans;:orter 1 Compaq Name U.S.EPA umber <br /> Clear. Harbors Environmental Sen-ices mc. MAD03932.'250 <br /> 7 T-arsspwUr 2 Company Nerve U 5'EPA 10 Number <br /> 8 U S.EPA'G lJ:irsber <br /> Cr-an Harbors PfttmnhiAuLv, LLC CAD980675276 <br /> ,lo <br /> -to ttiest lakem %05C!. Butta.wh r:vtr CC. 93106 <br /> Fa:z.r s Phone 651-752•§1Qr7 <br /> 9a 9b U 5 DOT Deso p6cn findudn;Pfapu Shbpinp flame,Hazard Class.la R wbtr 19.Conlamrs tt-flat 12 Ung 13 IYastm Codes <br /> Htr and Pa:kmg G'Dp d anyi} N5 Type Quarry MAV <br /> ' RG.NA221Z. Asbestos,9.111 (ERG 1711(DOPOUDE-i; ! CM 12D Y <br /> 151 ' <br /> 11 S;,e,aa.'ya.�,rrg 1rs and Ad�:a'a 1nt•.r:swabon <br /> r:m fgen�r Response Phone=23-42M Contact name LLNL EMergencY DlspatCh- Lead No-BTW w-m, ship Dec N_-S-237372- <br /> Reference release nurrber LXED106 on inywce.C 3D0:Sra. 0M No,C7•IHF2W57, 51YAPCD-43M ERtmp11;eWri,t+'Odeitc.Ca <br /> %x356 <br /> 15 GENERAMFrstOFFEROR'S CERTIFICATION. I hereby declare Shat ere contergs as trim a xurmm am h*and ecr 801 bscSO above by the proper LWpR9 name 91s1 are classified,po&aged. <br /> :narked and labeledFlaoarded,dnd are in al reapers as pow a�rsdb�s for troruaort atpbrdktQ b ipptca4te rder9� and naWrrel OCr9►v repuLttans ff export sspmenl ors,I am the Pmtary <br /> Ex:+erter r ner:?y anal the trrste'rt of��nrxrr canla-n b the fervors of t:e a�"hed EPAA�.'torrled�gnert of Ca-srr! <br /> t cer:fy trot tha wasx mmrumbors st9xrner'g x;ertdied n 40 CFR 262 2719){g i ten a largo q,:an:h generatph p lb4 id�am a sinal Quamly n hue <br /> Gw.ral:e&,Mrors Pnrradliyped Name 1Amss Day Year <br /> 5-4: A Graham on behalf of NNSA <br /> -j 16 tntemaaw priers ❑tmparl U U S. ❑Esport hoes U S Port of entrylext <br /> Tran=.a r sprat.-ru lbr vapors or#- Oatr leawng U 5 <br /> r�u 17-ria:s rtark"c %TrrrtdRece,pd6ta9ertals 1Janri oar Year <br /> 1 -Typed Name SgnoRne <br /> C aQ <br /> aF ger Tra-. 2 Prr%d yptd Nan* SrerwWY labnlh Day Year <br /> 18 C rGarwy <br /> 1 D Ekscreva-ct h caw Space ❑ 0ssanuy ❑True ❑Resdue ❑Partial Ra. ❑FW"It., <br /> %wdest Rekrence Nxnber <br /> lab AP.ema!e Fac:w,or Genera'drt U S EPA L3 Nxter <br /> 1 <br /> U <br /> rQi Fa;..-ty.Pnorw <br /> I Bc Sr2-satim ol klerm.Ite Faagy for Generazrl Maras Wy Year <br /> x <br /> 19 Hazardan Waste Report Mersa7,emerd McCrod Codes[rat C.codes lar ha:ardoua waste WftnwL dmDosal and recyc*501eff3] <br /> c 1 2 � 14) <br /> �1 20�essrmateu Fscll.ty Omer or O-,.ara'�t Certan a!reanptollsazarCo�s matarras mwnW trr bre sra'utesl rasd N Item tsa <br /> lPnturr Na-. Moro ! Year <br /> iE tl <br /> EPA Farr 8700.22(Rev 3451 Previous tans are obsolete DESIG ILrTY T DE NATION STATE (IF RECUIRED) <br />