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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTEMANIFEST CA2890090002 1 192S-423-1205005870992 JJK <br /> 5.Generator's Name and Mailing Address Generator's$ite Address(if different than mailing address) <br /> Lawnirn= Livemmre National Laboratory Srtr 3D4 for NNSA Lawrrencr Lr,vrmcrre National LaburaL^ry Site 3N for NNSA <br /> P.O . BCY 9021 L--?96 lsvrm-zrr CA 94551 corral Nvifah Road 'rrmcf C—A 95376 <br /> Generator's Phone: 925-322-1925 A I-rtj-Sts oolr-a <br /> fi,Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Erl-*DTlmental Services Ir1c. MAD039322'250 <br /> 7.Transporter 2 Company Name U S.EPA ID Number <br /> 8,Designated Facility Name and Site Address U S.EPA ID Number <br /> Clean Harbors Bsttnrwdttaw . Lit CAD98067S276 <br /> 25DO Wrct Lekern Road . Buttonwillow CA 93246 <br /> Facility's Phone' 661-762-6200 <br /> 9a 9b.U S DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 Conainers 11,Tola 12 Urit <br /> Hht and Packing Group(d any)) 13.Waste Codes <br /> No Type Quantity X-7121. <br /> 0 1. RCL NA22U usbestoi.9 ill EERG 171 t~ <br /> 1 {GCO22DE-1f f--M 20 <br /> � 15l <br /> z <br /> c� <br /> 4 <br /> 14 Special Handing Instructions and Additional Information <br /> Emergency Response Phone 975—423—42D5 Contact name l-LLL Err ergens'j GtspatCh <br /> Load ETW19-47 Ship ax No. 51-2411762 , R=rer,fn C* release number LY- t t]_rn_(9 ,3 on invotte <br /> =30M59. Bin No crrii;'20505 . SJV-4PM- 4aM Ente pinise Way, Modesto CA 95356 c*, ,�qj <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this cansd nment are fully and accurately described above by the proper shipping name,and are dassified,packaged <br /> marked and labeled,'ptacarded,and are in all respects in proper condition for transport according to applicable International and national governmental regulations.It export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknoWedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(it I am a large quanMy generaar)or(b)(if I am a small quantity generator)is true. <br /> GeneratoesOfferors PnniedlTyped Name signature Month Day Year <br /> Scott A. Graham on behalf of NNSA <br /> 1 16.Intematonal Shipments <br /> x ❑Import to U.S. ❑Export from U.S- Part of entylexit: - <br /> Transporter signature(for exports only); Date leaving U S: <br /> 17.Transporter Adwidedgment of Receipt of Materials <br /> Transporter 1 PnntedfTypecl ame .' Signature Montt Day Year, <br /> Q Transporter 2 Printedrryped Name — Signature Month Day Y r <br /> tr <br /> r- <br /> 18.Discrepancy <br /> 18a Discrepancy Indication Space ❑ Civantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Nur-ter <br /> 18b Atemate Facility(or Generator) US EPA ID Number <br /> J <br /> 'v <br /> W Faaftjs Phone: <br /> W 18c Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z1 <br /> 19 Haxsrdous Waste Report Management Method Codes(i.e.codes for hazardous waste treatment,disposal,and recycling systems) <br /> a <br /> 20 Designated Faai:ty Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnntkayped Name Signature 1/.J Month Day Year <br /> EPA Farm 8700-22(Rev.3.05) Previous editions are obsolete :' DESIGNATED FACILITY TO GENERATOR <br />