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RECEIVE <br /> Please print or type (Form designed for use on elite(12 -+ r' Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page i of 3_Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CA2890090002 1 192S-423- -4205 1005870884 JJ K <br /> eneraloes Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Lawrertrr Livsrmars Nntrrnad Laboratory Site 100 for NNSA U%mrem= Uvermore f'Intivnai Laporatsry Site 300 for r N&A <br /> P-0 Box 849 / L—796 Lvn-rare CA 94551 Conal Hollow Road, Trscv CA 95376 <br /> Generator's Phone:925-422-1915 AML Shiaaa-ra <br /> 5.Transporter i Company Name U.S.EPA ID Number <br /> C1ezn Harbors Environmental Services Inc. MAD039322250 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8-Designated Facility Name and Site Address U.S.EPA ID Number <br /> Ctedn Hnr+:Dm &--twnw14oH, LLL tAD980675276 <br /> 1500 West Ln;zm Rand. 9tittonwillow CA 93206 <br /> Facility's Phone: 661-762-6200 <br /> ga 9b.U.S.DOT Desuiption(including Proper Shipping Name,Hazard Class,ID Number, 10-Containers 11.Total 12-Unit 13.Waste Codes <br /> HM and Packing Group(if any)) Nc. Type quantity M,Nol. <br /> 1'RQ, KA22}? A5tl%tnS,9,til iEIRC3 1111 10Of'02208-1) CPQ 2'1 Y <br /> O <br /> 151 <br /> z z <br /> LU <br /> c7 <br /> '4 I <br /> d <br /> 14 Speval Handling Instructions and Additional Information <br /> Etrtergettcy ftesponae Phone 935.423-4205 corvtact narrre U-NL Ernerg <br /> Load No eTWL19-0;. Ship Geo_140.5-:37561, ftefc-retnce release No LXE7L <br /> SSVAPCU-41500 Enterpnsa t%ay.Modesto.Ca 95356 <br /> 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 dass$ed,packaged, <br /> marked and labeIediplacarded,and are in all respects in proper condition for transport according to applicable intemational 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 certfy that the waste minimization statement identified in 44 CFR 262.27(a)(if I am a large quan5ty generator)or(b)(if I am a small quantity,gaperator)is tri? <br /> Generator'sfOtferor's Prirted;Typed Name Signatu2 �f Month Day Year <br /> Scott A, Graham on behalf of NNSA ��-- <br /> -.r IF International Shipments <br /> z Elimport to U.S. ❑Export from U.S. f Port of entrylexlt; <br /> -- Transporter signature(for exports ony): Date leaving U S <br /> Ce 17 Transporter Acknowledgment of Ramipt of Materials <br /> Transporter 1 Pnnterflryped Name Signature Month Day Year <br /> O r 11r <br /> 06 <br /> )1 j <br /> Cn <br /> M¢ Transporter 2 PrmlaTypad Name Signature Month Day Yea? <br /> h- <br /> 18 Discrepancy <br /> 18a.Discrepancy Irdication Space ❑ Quantity ❑Type ©Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b Altemate FaciRy{or Generatori US EPA fo Number <br /> J_ <br /> U <br /> U- Faelity's Phone <br /> W 10c Signature ofAltemate Mintyior enerator) Manch Day Year <br /> a <br /> z <br /> L2 19 Hazardous Waste Report Management Method Codes(i.e.:codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1 �. 2 3_ 3 <br /> 20.Designated Facility O rer or Operator Certfication of receipt of hazardous materials covered by the manifest except as noted in Ileus t 8a <br /> Printed yped Name Ergnature Mprth ay Year <br /> EPA Form 8700.22(Rev.3.051 Previous editions are obsolete DESIGNATED FACILITY TO GENERATOR <br />