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Please print or type.(Form designed for use on elite(12-pita)typewriter) Form Approved,OMB No 2050-0039 <br /> UNIFORM HAZARDOUS I Generator ID Number 2,Page 1 of 3.Emergency Response PhoneManliest Tracking Number <br /> WASTE MANIFEST CA2940012SS4 } 1925-423-020S70058 <br /> f 0 AOJ 8 9 JJK <br /> 5.Generator's Name and Mailing Address Generator's S;tie Address(if d5erent than mailing address) <br /> Lawrence livmnore National Labera"- Cor'.'i;A Lo-x-enrr Lrvwmore National Labornmry for#INSA <br /> 7000 Fast Ave-L-M,L.vr:rmcre C.A 945SO 7DCta Last Ave,isvernrv,-e CA 9455D <br /> GeneratoesPhDne:925-422-1:925 ATnj Snrrsn;-a <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> Lawrence Livermore National Laboratory CA2890012S9d <br /> 7 Transporter 2 Company Name U S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Lawrercr Livermore National Laboratory, S-te 300 Lcirral IJa'!ow Road Tracy CA 953715- <br /> Facility's <br /> 537EFacility's Phone n,._4-.j , jr <br /> ga 9b.U.S.DOT Description Including Proper Shipping Name,Hazard Class,ID Number, 10.CDntairers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(it anyl) No Type Quantity wi Nol. <br /> 0 1.UNO475, haste,Substances.Rxrt_---snre n as i(PETN.ADX a P <br /> (DOT-39 L5,M) [ERG IUJ EWSF <br /> s 2 <br /> W <br /> C7 <br /> 3 <br /> 4 <br /> 14,Specal Handling Instructions and Additional Information <br /> Errlt►rg>Mcr ltesptzn;t Phone 925 ii33A2?15 ContCt name LLNt Err'esger>cy #sir Fctti.l❑a f 1�r F 19-82. 3h C}a bio. L• (la; <br /> C::+iltdlri�r� �i� C�7iJ3OFi�7Q. Ci�3�,fi�. ��3rJ63LO <br /> 15 GENERATORVOFFEROR'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 labeled,'p acarded,and are in all respects in proper condition for transport according to appi cable intemationaf 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 EPAAckno-Aiedgmenl of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262 Via)(d I am a large quantity generator)or(b)(if I am a smal quantity generator)!,true. <br /> Generator'sf0fferor•s PnntedfTyped Name S gnature Month Day Year <br /> Scott A. Graham or,behatt of N NSA l0,3 n7 <br /> —J 16.International Shipments <br /> 1— ❑Import to US. ❑Export from U S. Port of entry.'exit <br /> Z Transporter t <br /> si naure(for exports only): t <br /> 9 Po Y) Date leaving U.S.. <br /> 17.Transporter Acka iedgment of Receipt of Materials r� <br /> Transporter 1 PrintedlTypejName Sign ' Month flay Year <br /> CL <br /> zQ Transp(Wer2Printed'T}pedName "5igrs lute' f Month Day Year <br /> fY C.✓ <br /> 16.Discrepancy <br /> 18a.Discrepancy Indication Space ype ❑ i ElFutl Rejection <br /> Quantify 11 T ❑Residue Partial Rejection <br /> Manifest Reference Number: <br /> 18b,Qlarnate Faolity(or Generator) U S.EPA 10 Number <br /> V <br /> Fa36�'s Phone <br /> LU 18c.Signature of Alternate Facility(tor Generator) Month Day Year <br /> a <br /> a <br /> 19.Haardcus waste Report Management Method Codes Le.,codes for hazardous waste treatment,disposal,and r_orJing systems) <br /> Gi r rr 2 3. 4. <br /> - '�/ <br /> 24.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered try the manifest except as noted in Item iiia <br /> Prigtedlfyped Name l Signature s Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. <br /> DESIGNATED FACILITY'S COPY <br />