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M 3lV E ire Please prinfor type.(Form designed for use on elite(12-pitch)typewriter.) 'ta��■�•--4 Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number- 2.Page 1 of 1 3.Emergency Response Phone 4.Manifest Tracking NNumrWASTE MANIFEST C-47R4009 0? rL 925-423-4205 inn ,;=be767 JJK 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Lnwrtm=Uyerrrtarre National UL-nratary Site 300 fur i;NNSA Lawrenta tiverirvore National Lx�=wvey SatL 3C0 forNNSA P 0 Box 308/L-786,Livatsrtom CA 94551 f'arrnl lik,41ow Road I 'racy,CA 95375 Generator's Phone:925-422-1925 a MT4-ChMlnnpne 6.Transporter 1 Company Name U.S.EPA ID Number Clean Harbors Environmental SenAces Inc_ MADQ93?2250 7.Transporter 2 Company Name U.S.EPA ID Number Z! Z- B.Designated Facility Name and Sbe Address U S.EPA ID Number Clean Harden in Parte.LP. TXD992290140 500Parkway Scutli,La Porte TY.77581 Fadkty'sPhone- 104_oo�.cann ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12,Unit 13.Waste Codes HM and Packing Group(ii any)) No. Type Quantity KR.NoI. O 1 UN1.978, Waste,Propane,2-1 (ERG 1151 LLNI.A:Y15-1 1 pr P D001 t— 331 Oct E 2"UN1060, VVaste,Methyl acetylene and propadfene mnaures, ;fir , ,- 13001 stabilized,11(DOT-SP 6688) (ERG 1151 LtNL-LCY6-I 331 r�L.1 C r 3- 4. 14.Special Handling Instructions and Additional Information Emergency Response Phone 925-423-42D5 Contact name L NL Emergenci Dupatch.Loud M Lgia-G2, ship Doc Na. 5-aq$�q:-. Refuertce rele3it3tfm eer L3a0542 on invoice.9b-L 00027V]58 --•I5G Of X 7cY,9b.2- Qwzvml -•5G DF x r. 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of th s consignment are fully and accurately described above by the proper shipping name,and are classified packaged marked and Iabetedlplacarded 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimizabon statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b1(if i am a small quantity generator)is true. Generator'sl0fieror's PrintedrTyped Name Signature Month Day Year Scutt A. Grahairl an behaFf of NNSA A&;2 -77 1 1,0 J 1 16.international Shipments �--�— Z ❑Import to U S. EDExport from U.S Pod of entry'exit: Transporter signature(for exports only): Date Leaving U.S.: w 17.Transporter Ackncv!edg'ment of,Receipl of Materials ! CeTransporter 1 P ted/Typed Na f Signature f ,- `/ Month Day Year CL Q Transporter 2fPnntedr Md Name / (Signature '-" / Month Day Year 18.Discrepancy 1 taa.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue Partial al Releciion Full I Reiectian Manifest Reference Number 1 O.Alternate Factiry far Generator) US.EPA ID Number V Faci!ity's Phone: LLN 18c.Signature of Altemate Facility(or Generator; hlanth Day Year a a N19.Hazardous Waste Report Management Method Codes a.,codes for hazardous waste treatment,disposal.and recycling systems) ter n 1 2. 3. a 20.Designed Facil.ty Owner or Operator;Certification of receipt of hazardous materials covered by the manifest except as nded in Item 1 Ba PnntedfTypedName Signature Month Day Year EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR