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Please print � p type (Form designed for use on elite(12-pitch)typewrter.j Form Approved.OMB Na 2050-0039 UNIFORM HAZARDOUS1•Generator ID Number 2 Page 1 of 3.Emergency Response Phone 1058.70803 nifest Tracking Number WASTE MANIFEST ICA2890090002 1 1925-423-4205 JJK 5.Generator's Name and Mailingg�Address Generator's Site Address(if different than mailing address) Lawrent a Uve=ore N7tional Laboratory Sita 20D ler NMA Lawrence Uvarrnorr Nationel Lr:borawry Site 3CO fcrNNSA P.O.9ox 848/L-".a6 Liyermarv, CA 94551 Corral Iaolla-m RAad. Traev CA 45376 Generator's Phone:925.422-1375 A i7N:Shipping fi.Transporter 1 Company Name U.S.EPA ID Number Clean Hatters Environmental Services Inc. MAD039322250 7.Transporter 2 Company Name U S.EPA ID Number 8,Designated Facility Name and Site Address U.S.EPA ID Number Clem Narbars 9uttanwilfow,LLC CAD980675276 2500 West Lnkem Road. Buttonwillow CA M06 Facili 's Phone: 661-762-5215© . ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.ContainersI 11.Tata' 12.Unit 13 Waste Codes HM and Packing Group(if any)) Nn Type Quantity WLNoI, Non4CRA hazardous waste,solid(non-PCE capautors) 156 9 P z 2. L r.7 4. ------------- 14.Special Handling Instructions and Additional Information - Emergerrcy Response Phone 92:423-4205 ContaCs name U.NL Emergency Dispatch. Load No.13wi:S-o8, Strip Cir_No.5-229347, Re`ixrenre relaase number) i0a61 on invoice. 5c4 a La hed for containernurnbep 15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and a=rately described above by Me proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.Ifexport shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. t certify that the waste minimization s'aternent identified in 40 CFR 262,27(a)(if I am a targe quantity generator)or(b)(if I am a sma!I quantity,generator)is true. Generetor'slOfferor's PrintedrTyped Name Signature Month Day Ye Sc att A. Graham on behalf of NNSA (� --r 16 International Shipments F— ❑Import to U S. ❑Export from U 5 � Portof entry'exit z Transporter signature(for exports only}; Data leaving U.S.: 17.TransporterAcknawledgment of Receipt of Materials LU TranTrter 1 P ted,yped Name SignatureMonth Day Year CL a Transporter 2 PrntedlTyped Name Signature --r Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Quanti. ry El Type ❑Residue ❑Partial Rejection Manifest Reference Number. 18b-Alternate Facility(or Generator) U.S EPA ID Number U rat Facdiy's Phone LU 18c Signature of Alternate Facility for Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes(i.e.codes for hazardous waste treatment,disposal.and recycling systemsf 0 1• r 2. 3. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18@j^ PnntedfTyped Name �� f Signature s Month Day Year EPA Form 8700-22(Rev.3-05)'Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR