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� REUIVED <br /> Please print or type.(Form designed for use on el to(12-pitch)typevmter.) Z 1 I q <br /> T. <br /> WASTE MANIFEST CA289009000? 9e1 3 e n R nsePhana 4,ManlfaslTraekIngNumber <br /> 5 Generator s Name and Ma i ngAddddres 1 925-423r-4705 5 Q JJ K <br /> Lawrence vetrn! IYab",I Laboratory Sjts 300 for NNSA Generarors 5ileAddress[rf different than marling address} <br /> P. . 9rrx 309 j L-79f Liverm,30L Lawrmr� Livrnnorc Nati <br /> orHollow RoadTia SF--Siir�96—for--N <br /> Generatoes Phone 925.422-1925 c1 CA 95375 <br /> 6.Trans ATTN:Shipping , <br /> Transporter 1 Company Name <br /> Clears Harbors Environmental Services inc_ tr. EPAIDNumber <br /> 7,Transporter 2Com'paan`yName MA0039322250 <br /> ✓r �• �e fjr f�-�n�ff1 U.5 EPAluriumber <br /> 9 Designated Facility Name and Stla Address "d 17d jD.3 g <br /> Clean Harbors Aragonite, LLC U S.EPA it]Number <br /> 11500 North APtus Road, Arattonite UT 84029 UT0981SS2177 <br /> Facitttys Phone. 435-884-8100 <br /> 92 9b.U S.ROT Description,nduding Proper S''ipping Name,Hazard Class,ID Number, <br /> HM and PackingGroup[dany, T9 Ca9ta;ners <br /> 11.Total 12.Unit <br /> 1. UN3379, Waste,Desensttlzed explosive,liquid,n.o.s.(HMX.RDx , No. Type Quantity WtNVol 13.Waste Codes <br /> 3,1(00T-SP 15448) (ERG I.28) (COPG354EX-1) � Z 0lvl 898 P 0001 F005 <br /> w <br /> CDR 2 R0.UN3432, Poiyahlonrlated blphenylw solid,9.111(out of Service 3a3 <br /> Date 07/1012015) (ERG 1,71) (uOPoon-1) 1 DF 22 K <br /> 3. 751 <br /> 4 <br /> 14 Special Handling Inshuctiorts and Addiha9ai IrsiCrmaG�n <br /> Emergency Response Phone 9 ,433-4305 Contact name <br /> Load Na. APTL9-02, Ship 0nc No. .5-2374WVL Emergenc�r Dispatch. <br /> 5ee attached for container numbers_ Refer�Tce release number LXE0103 on invoice. Used light ballasts. <br /> 15. GE ked and R'SIDFFEROR'S CERTIFICATION:thereby declare Ihal the contents of this consignment are fully and aoarrately described attave by the er s ' <br /> marked and fabeladlptae conte and ora in a!!respects in proper condition far transport according to appficalfe kttema6anal and national governmental regulations.If export sh pment and i am the Prim <br /> Exporter,I certify Ihat the contents of this consignment conform ro the farms of the attached EPAAcknowl Prof tppN' i name,and are rlassi5ed,packaged, <br /> I certify That the waste min mizatioe statement identified in 4Q CFR 262.27{a}(ii I e a a c PAA edgmenl of Consent a <br /> Genetatnrslofferor's Printedfiry <br /> yped Name largeq ty generator}or(b}{it I am a small qu ntity generator store <br /> Scott A- Graham nn behalf of NNSA Signature <br /> P- 16.Intemabonal5hipmants <br /> Month DaY Year <br /> Z Trans ❑Import to U.S. !(� <br /> Transporter signature[for exports any}: Export from U S _1 <br /> 1sr Podotanlrylaxit <br /> 17,Transporter <br /> 9mer'of Receipt at Materials <br /> Dale leaving U 5 <br /> M T over 1 PrintedlTyped <br /> O <br /> CL �AJ S' re <br /> / <br /> sparter��yped Name Month Day Year <br /> Signa re <br /> 01 �5 <br /> 18 Discrepancy <br /> Month pay Year <br /> IBa Discrepancy indication SpaceG <br /> ❑ Quantity �Type ❑Resdue <br /> Partial Rejacton El=ull Rejection <br /> 19b.Allemate Facity{or Genaralor} fvlanofesl Reference Number. <br /> � <br /> Foci itys Phone; U S.EPA iD Number <br /> j 18C.Signature of Altemata Fauiliry(or Generator) <br /> 19 Hazardo-,s Waste Report Me,nagemerI Method Codes(.e.,codes for hazardous waste treatment,des sal,and i htcrth Day Year <br /> 1 <br /> ! 'O L�ito 2. f p' ngsYslems) <br /> Hao 3 <br /> 4 <br /> 20 Designated Faclity Owner or Operator Certification of recerpl of hazardous mater-As covered by the manifest except as nded In Ile m 19a <br /> Printedfrme Name <br /> -N h Signature <br /> Farm 8700-22(Rev 3,05) Previous edilions are obsolete. Month V ((Your <br /> 1y I t <br /> DESIGNATED FACILITYTO <br />