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tivitu r RK Please print or type (Form designed for use on elite(12-pitch)tOewiter I r Farm Approved.0106 No.2050.0039 UNIFORM HAZARDOUS I Generator Ip Number 2.Pagel of 3 Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST I CA2990090002 9 192S-423-420S inn5unpi Q JJ K ! 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) Lawranre Uyarrnnre Natuna!Labormwry iAL-306 for►aNSA lawrnn=Liverrrrara National Ls�z=tcry Site 1,0 for-NNSA P.O.Pox 808/L-185 Livermore CA 94551 Corral Ftoflow Rozzl jraey,CA 953?6 Generators Phone: 915.421-1925 L?Tf� tkirrn's-,o 6.Transporter 1 Company Name U.S.EPA ID Number. Clean Harbors Environmental SeM--as Inc. MA13039522250 7.Transporter 2 Company Name U-S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number CIL-an 14arborr,of San Jose,LLC 1021 Re-vessn Poad.San JUseCA 95131 CAD059-49a310 4D6-451.500 f Fadlit/s Phone: ' 9a. 9b.U DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit t Waste e HM and Packing Gawp(4 any)) No. Type Ouanbty WI.Nol. tz 1'Residue. Last Contained UNL9't33,Flarnfriabie liquids,n.o S. 1 DNq 52 F jacet-�ne, ethyl a-Etate).3, H [ERS; ;LZi( fir-W46-I 512 Z0001 U076 U002 r ul UN L972, Waste,Flammable itqutds-to}os,n.s.s.,3(6.1), 11 (Lab P { t� 212 park)IEPlG U111 f7GPOklb-L �331 3.LN L993, Wi3ste.Flammable hquids,n.o_s.,3.11 (Lab patio)luu r DOOL I L•Bl iilCt=C11i6-i 11 331 4. UN12M, Waste,Petroleum disitllates,n.a.s..3,111 (ER'; 1291 39 a [GJ1 C OPOC154-'` 331 14.Sdecal dandling Instructions and Additional Information Emergency Response Phone 915.423-42tD3 Contact narine LLNL Emergency[Aspatrh_Load 11 541&21., 5htp Doc No.5- � , deference release number�E_� ort invoice. attacheci lose Gofti3ir1Er r�urnhef 53VAPN--48M£nterpnse Way,Modesie,Ca 95356 1`t i� r C n'��/.k�� 41 15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this 05-signmenfare lully and accurately descnbff'above-by the proper shipping name,and are classified packaged marked and labOed'placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and l am the Pnmary Exporter,i certify that the contents of this consignment conform to the terms of the attached EPA Ackwuledgment of Consent. I certify that the waste minimization statement identi_5ed in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true GeneratorslOfferoes PdnWJTyped Name Signature r Month Day Year �� .r, Wt ten n,;\ knr.�.n�t -`� �� e.4 /� DS - IR J 16.International Shipments t-- — v i- ❑Import to U.S. ❑Export from U.S. Port of entrylexd Z Transporter signature(for exports only): Date leaving U 5-: w 17.Transporter Acknowledgment of Receipt of Materials �� p 16; Tran�pcirter 1 PnntedlTypedNam)e f Signature �f / Month Day Year a. UV nlh/I.�r: Hct r f~p \ /r� h z+? (R a Tmkorter 2 PnntediTyped Name Signature Month Day Year H 13.Discrepancy iiia.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejencii ❑Full Rejection Manifest Reference Number. r 13b.Alwrnaie Facility(or Generator) U.S.EPA ID Number J_ U ti Facility's Phone: W 18c.Signature of Altemate Facility(or Generator( Month Day Year a z 19.Hazardous Waassttee Report Managgeement Method Codes(i e- codes for hazardous waste treatment,disposal,and recycling systems)) Cn 20-Designated Faci.'ty*rmer ar Operalor•Ce6fica5orl of feceipt o!haiaC/rd�aus materials covered by the masrfest except A noted in hem 18a, Printed[Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete.' DESIGNATED FACILITY TO GENERATOR