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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0 UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3 Emergency Response Phone4.Manliest Tracking Number WASTE MANIFEST CA2890090002 L 1925-423-4205100woUn JJK 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) I.awrence Livrrrrtam Nstmnnl La6crotary Site 30D forNi4SA Lawrenm- L-owmcre NaLlondi Laborawry Sita 10,0 for NNSA P O 8;,x 008/L - 726, Uverrnom CA 94551 Carrel Hallow Rozd, Trrry C 95276 Generators Phone: 425-Q 22-1925 ATTH:Shiratria 6.Transporter 1 Company Name U.S.EPA ID Number Clears Hi3rbors Environmental Services loc- MA00393.222SO 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Clean Harbors GuttAnwillaw, LLC CA.098067527E 2500 West Lokern Arced, EuUnnwi law CA 932G6 Facility's Phone: RK1-7A)-ronn ga 9b U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, i0 Containers 11.Total 12 Unit 13 Waste Codes HM and Packing Group(if any)) No Type Quantity Wt 10011. O 1 RQ W2212,Aibeitos,-9.fill (ERG 171) (17,0(702206-1) M 20 f r 0 w c� 14.*tial Nandiing Instructions and Additional Information Lmtrgency Response Fhone 425-4 3-422 Cornact name LLNL Errergency Dispatch Load No.EiV"d1-1;-[13. Ship Reference release number xLf-'n invoice.QX-300778 Sin No.CHH172MBO 5JVAPCD - 4&M Ernr4pnsrc L'V* Pitodesto,CA 95336 1 y 1) C; -; n 1 f 0 J 15. OMERATOR'SIOFFEROR'S CERTIFICATtON: I hereby declare that the contents of this consignment are fuliy and accurately described above by the proper shipping name and are classified,packaged, marked and labeled;placarded,and are in a!I respects in proper condition for transport according to applicable internationaiand 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 EPAAckncrMedgment 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)(it I am a small quantity generator)is true. GenemtorslMror's Pr riled7yped Name Signatures �. !,( Month Daffy+ Year Scott A- Graham on behalf of NNSA —J 16.International Shipments F- ❑Import to U.S ❑Export from U S. Port of entrylexit: Z Transporter signature(far exports only): Date leaving U S W 17.Transporter AckwMedgment of Receipt of Materials a Transporter 1 Printed/Typed Name Signature Month Day Year M4rig,, 'Lr 111 L=fI� ` '�,Al�-�� s✓t� �) f� za Transporter 2 Printed+Typed Name Month Day Year tY 18.Discrepancy I Be.Discrepancy Indication Space ❑ � ❑Type ! j lection Quantity ❑Residue El Re ectian ❑Fu:l Re' Manifest Reference Number. 18b Altemate Facility(or Generator U.S.EPA ID Number U res Faciity's Phone W 16c.Signature of Altemate Facility i.or Generator) Month Day Year a a N19.Hazardous Waste Report Management Method Codes'i.e,codes for hazardous waste treatment,disposal and recycling systems; LLi 0 11 / 2.1'? ( 3 4 20 Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by She manifest except as noted in item 18a Pnntel!i pecl Name Signature Month Day Year EPA Form 8700-22(Rev.3.05) Previous editions are obsolete DESIGNATED FACILITY TO GENERATOR