Laserfiche WebLink
MUM r9 <br /> i`b <br /> Please print or type.(Form designed for use an elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> 11MIFORM HAZARDOUS 1.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 7005870798 <br /> Manifest Tracking Number <br /> WAST-1.1-1-1 EST CA2890090002 1 192S-423-420S JJK <br /> S.Cwwmraes Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> tawrer.= Eivermom National tahtiraWry Site 300 fcr NP4S.A iawrertr lilrrrrore Hauortal Ubnr awr7 Site]tis? for MASA <br /> P.O.fio%808/C-T86 tivefrrom CA 94551 Ccsrrat ffoilrlw Road. Tray CA 95376 <br /> Generators Phone:925.422-1975 ATTN•'h'nrxna <br /> 6.Transporter 1 Company Name US.EPA ID Number <br /> Clean Harbors EnArbllrnemal Services Int. MAQQ39;22250 <br /> 7 Transporter 2 Company Name U S.ERA ID Number <br /> 8.9t5:K9ed Facility Name and Site Address U.S.EPA ID Number <br /> Ctean 4far cars eutt=nwtbw, LLC CA098067S276 <br /> 2500 West Lclkern Rood 2uttonari97w CA 912M <br /> Facility's Phone: cc.1_zcl-clr%A <br /> 9a gb.U S.DOT Descrpbon(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Guanriry Wt.Nol. <br /> W 1.Non-R,-RA hazardous waste,solid(noir+tom_apacnors) 17 CVV 34255 P <br /> W 773 <br /> Z 2. <br /> W <br /> r, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> _ ger ar�tstoy.li�s.}xans Pl-sae925�473421- contact nafr*LLNL Erlergency Dmpatch <br /> Load No ETVV! -05. Ship Doc.W 5-719537, fiefereme release number LS!imo on iinwofca 5"artach Ed far r-cmamer numbers <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 classified,packaged. <br /> marked and laWed'placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations If export shipment and I am the Primary <br /> Exporter,t certify that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent. <br /> I certify that the waste minimization statement ident ted in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(it I am a smatf quantity generator) true <br /> Generatior'lVerors PrintedlTyped Name Signature Month Day Year <br /> Scott A- Graham on behalf of NNS.A 10J4 10-r' <br /> —1 16.International Shipments ..�.� v <br /> t` El Import to U.S. El Export from U�.,S. Port of entrylexic <br /> M Transporter signature(for exports only): Date leaving U S <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Tram` iter 1 Printedf yped Name Sign ftu e- Month Day Year <br /> A4 I <br /> a <br /> —transporter 2PNntedfrypedName'" " Sknabre —} i Month Day Y44f <br /> ix <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepatrcy indication Space Guano Residue <br /> ry ❑Type ❑ C1 Partial Resection ❑Ful1 Resection <br /> Manifest Reference Number <br /> 16b Alternate Facility for Generator) U-S.EPA ID Number <br /> Ca <br /> Facility's Phone <br /> W1 ec Signature of Attemale Facility(or Generator) <br /> t— klormr'. Day YPLL' <br /> a <br /> Z <br /> 19 Hazardous Waste Report Management Method Codes(re codes for hazardous waste treatment,disposal.and recycling systemsl <br /> LU <br /> 20.f7esgnated Faal. 0, --s6r or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnntedlfyped lame i/ i Y Signature Mi ntl' DE!, Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete DESIGNATED FACILITY TO GENERATOR <br />