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cCg�, RECE IID M Please print or type.(Form designed for use on elite(12- af!4(�? Form Approved.OMB"No.2050-0039 UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 1CA289009G002 11 925-423-4200 1005870881 JJ K 5.Generators Name and Mailing Address Generator's Site Address(if different than malting address) Lawromm Livermare National Labarawry Sift: 300 for NNSA Llvarencm 13n4n-jre N&6znal Laboratz:rsj Site 300 for NNSA P.0 @o% 902/L-786 Livermore CA 94551 Carrel Hvllvw Road, Tracy CA 95376 GenaratoesPhone 925-422-1915 A7FN- >,t�ninn 6.Transporter 1 Company Name U.S EPA ID Number (lean Harbors Environmental Samicas Enc. MAD03-4322250 7.Transporter 2 Company Name US EPA ID Number 8.Designated Facility Name and Site Address U-S.EPA ID Number Clain Harbon Buttorrvrillow, LLC CAD980675276 2500 West team Hoar~+, Buttnnwilfow CA 93205 Facilitys Phone 661-762-6200 ga. 9b.U.S.DOT Description(mcluding Proper Shipping Name,Hazard Class,ID Number, 10.Contalners I1 Total 12.Unit 13 Waste Codes HM and Packing Group(if any)) No. Type Quantity WtJUol. 1. iX 1/ RCL RA22a Asbeitos,9,111 JERG 1711 (DCIPOZ20e-ll ta.t t7 J r r 14.Special Handling Instructions and AddMnai information j EMefg*rtcy Ftesponst Phone 92--y-4?3-4205 Contact name LLNL Emergency Grspatch. Load Nu.ETWL9-m Ship Dot No.5-23)373, Reference release number LXEDLM on invoice. gt]=784. Stn No.CI-frfP20300. SJVAPC'D—41M Enterpnie Way,Modesto,CA 95356 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 dassified,packaged marked and labeled'placarded.and are in alt respects in proper condilim 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 EPAAcknowledgment of Consent. I certify that the vraste minimization statement identified in 40 CFR 262.27(a)(if I am a large quanftj generator)or(b)(if t am a small quantity generator)is true. rS:ccwrrr rsnbtferors Pdnted7yped Name Signature .Month Bay Year A- Graham or, behalf of NNSA ,l � � I Q1 Z4 I IR —j 16 intemabonal Shipments i- ❑Import to U S. ❑Export from U.S Port of entry.'exit: z Transporter signature(for exports only) Date leaving U.S.: LU 17 Transporter Acknowledgment of Receipt of Materials Transporter 1Psinied(Typeq/Name �,c Signature Month Day Year QTransporter 2 PrimediTyped Name Signature' Month Day Year a r- 18 Biscrepaacy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Referer ce Numbt-. 18b.Altemate Facility ter Generator) US EPA ID Number J_ C-1 LIZ Faa'litys Phone: cm 18c.Signature of Alternate Facirty(or Generates) Month Day Year z Cn 19 Hazardous Waste Report Management Method Codes(L e.codes for hazardous waste treatment disposal,and recycling systems} 4. 20.Designated Facility Owner or Operator;Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a PnnTyped Name 1 T signaWre) i Month Day Year-, EPA Form 8700-22(Rev.3=05) Previous editions are obsolete, / - DESIGNATED FACILITY TO GENERATOR