Laserfiche WebLink
REC <br /> t <br /> Please print or type.(Farm designed for use on elite(12 pitch)typewri ert.) ved OMB No.2050.0039 <br /> UNIFORM HAZAROOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.M87-1t. 009 <br /> acking Number <br /> WASTE MANIFEST CA2890090002 1925-423-4705 JJK <br /> S.Generator's Name and hlall,ng Address Generator's Site Address(4 different than mailing address) <br /> Uwrence Uvernnore National Ulacratnry StLe 340 for rJNSL a Lawrence Livermorr National Laboratory 5itr 300 for NNSA <br /> P.O.Box 5Dt3/L-7f16 Livermore CA 54551 Corral Hcl;ow Road Tracy CA 95376 <br /> Generator's PhenT 925-422-1325 ATTN--Sivaaintt <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Environmental Services Inc. MAD039322250 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Silo Address U.S.EPA ID Number <br /> Clean Harbors of San lyse,LLC CA.DOS9494310 <br /> 1021B_rrymia Rced `an Jute CA 95133 <br /> FaditrsPhcne 408-451-5000 <br /> ga 9b.U.S.DOT Description"uding Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(rf any)) No. Typo Ouantty WtNci. <br /> c \ 1'UNIM. Waste,Flammable hqurds,n.o.s..3,It (Iabpack)(ERtr U51 ! S F D001 <br /> riopol:6-1 <br /> 331 7n1 <br /> 2,UN1ZZ3, Kerosene,3, Ut (FRG M) DOP0051-1 DM S P <br /> IX <br /> 3 tlN1309. Alumtntl n powder,coATed,4,1, it ilabpack)(ERG 17131 ONI 1-TL P <br /> t3OP0117.1 141 <br /> UN335S. Waste.Corrosive liquid.acidic organic.n.c.s.8 It 0007 <br /> Y' <br /> ` jtabpaJr)(ERG 1531 DOPOLL4-1 731 <br /> r <br /> 14.Special Handling Instructions and Additional Information <br /> Ennemenvi Response Phone 925-4 3-i:.`0'S Con*act name LWL EniefSeoclj DtspatCh,Load k 5,L9-22. Shap rpt rile.5.247571 <br /> fieferenee release number MOM,on Ifivoice.Sae aLtachE4 for container ntlmbeTi <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desc ibed above by the proper shipping name,and arc classified,packaged, <br /> marked and tabeledlplacarded,and are in all respects in proper condition for transport according to applicable intemational and natonal governmental regulations.If export shipment and t am the Primary <br /> Exporter,I certify Shat the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minim'¢abon statement identified in 4D CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratorslOfferoes PrintedlTyped Name Signa. x Month Day Year <br /> Bradley Shninger, an behalf of NNSA <br /> ...r 16.lntemational Shipments <br /> Z 11Importto U.S. ❑Export from U.S. Part of entrylexit: <br /> Transporter signature(for exports only): Date leaving U-S-: <br /> LW 17,Transporter Acknaaledgment of Receipt of Materials <br /> Transporter 1 PriW'Typeed Name Signature] s 1 Month Day Year <br /> 01,1.e v <br /> z¢ Transportet 2 PrintedlTyped Name / Signature Month Day Year <br /> � J <br /> 1- <br /> 18 Discrepancy f <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Re eMien ❑Full Rejection <br /> Manifest Refirerce Number. <br /> 18b.Alternate Facility for Generatarl U.S.EPA ID Number <br /> i.7 <br /> Las. Fa,lity's Phan.: <br /> 18c.Signature of Altemate Facility(or Generator) Wr4R Day Year <br /> a <br /> z <br /> N19.Hazardous WasteReport Management Method Codes(f.e.,cod—e�s{for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> G 1 11 2 I I ( 3. <br /> � Z-711 t T1 <br /> 20.Des grated Facility Amer or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16a <br /> Pmnted Typed Name ; J Signature w Ih 1Day Vila <br /> EPA Form 8700.22(Rev 3-05)'Previous editions are obsolete: DESIGNATED FACILITY TO GENERATOR <br />