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101LIM), <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator le Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST CA2890090W2 3 922-423-4205 1005870801 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Lwwrents Lve rrrore N stional tzboramry Site 3Li0 for NNSA Lawmmn=Liver=ry Natiorrai Laboratory Sift 300 Far PSN 5A <br /> P_0.Bax t306 J L-7&S Livermore, CA 94551 Carrel HoLow Read Tracy. CA 95376 <br /> Generator's Phone:925.422-1925 ATTN;SFMc;rljt <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Environmeri-tal Services Inc MAD039322250 <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site Address US.EPA ID Number <br /> Ci=arm Hari:rorx Buttnnvr9tnw,LLC CAD90575276 <br /> 2.500 West Lskam [Read, Buttrnw:-nw CA 932Q6 <br /> Facility's Phone: fotrt_7K 7.F,)nn <br /> ga, 9b.U.S.DOT Description(induding Proper Shipping Name,Hazard Class,ID Number, 14.Containers 1t Total 12.Unit 13 Waste Codes <br /> HM and Packing Group(if any)) No Type quantity WtNol <br /> 1.Nan-RCRA hazardous waste solid(non-FCB caW-Tiori) ;$ CW 31093 <br /> (r�C1Ppl;7Z$-L) Zig <br /> w <br /> t7 <br /> 3 <br /> 4 <br /> 14.Special Handling Instructions and Additional Information t <br /> Emergency Response Phone 925-423-42175 Contact name LLNL Emergency Ekspatch <br /> Load No.RTW 1"7. Ship DOC tWj_ 5-ZI%39, 96fe-fence release nturtber LS.I0965 on invoice. 5rie attached for container numbers <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION:i hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labele ftlacarded,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,I certify that the contents of this consignment conform to the terms of the attached EPAAcknoMedgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262 27(a)(it I am a large quare y generator)or(b)(if I am a small quantity genpera or)is true, <br /> Generator'sfOfferor's PrintedTyped Name Signature ,� Month Day Year <br /> Scott A. Graham on behalf of NNSA O q 161 <br /> 16 international Shipments <br /> s ❑Import to U.S. ❑Export from U.S Part of entrylexit: <br /> Trarsporter signature{for exports only): Date leaving U.S.: <br /> 17,Transporter Acknowledgment of Receipt of Materials <br /> Tr} <br /> ag)Wrter 1 Pn tedTyped Name \1 Signature Month Day Year <br /> CL U <br /> Q Transporter 2 PnntedrTyped Name Signature y��� Month Day Year <br /> rY <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy lndimton Space El <br /> Quantity 1:1 Type 1:1 Residue ❑Partial Rejecto^ ❑Fu':I Rejedicn <br /> Mw1est Reference Number: <br /> Ifb.Altemate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> F.c4.Vs Phone: <br /> 1 Bc,Signature of A:temate Facility(or Generatan Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems: <br /> � i f <br /> 20.Designated Facility, r or Operator.Certification of receipt of hazardous materials covered by the manifest except as crated in Item 18a <br /> PnntedlTyped NaTe / � lam ' 5 gnab! � 0 r Dayrd'116 <br /> EPA Farm 8700-22(Rev,3-05) Previous editions are obsolete. DESIGNATED-FACILITY TO GENERATOR <br />