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Please print or type i7omn designed for use on elite(12-pitch)typewriter.) Form Approved OMB No 2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CA289001.2584 1 1325-423-4205 100587 016 JJK_ 5.Generators Name and Mailing Address Generators Site Address(if dalerent than mailing address Lawrencm Livwn torn �Vatono]Lcboratory for NNSA7000EattAve-- La wren=Liuecrrcre Natr ral Loborivtar/ arNNSA?j0 F astAwc L 796 I.rvrfrrcrra CA 9455D Uvrermore CA 94550 GeneraloesPhone: 925-422-1525 ATTN:ShWptrtg 6.Transporter 1 Company Name U.S EPA ID Number Lawrance Livermore National Laboratory CAMWUSHw 7.Transponer 2 Company Name U S.EPA ID Number 8.Designated Facility Name and Site Address US EPA ID Number Lzwrcnze Livefmore Natorral Lsbcratery,Site 300Cvr-al Hollow Floati T=f CA 35376 ;�A2890090002 Far:Oys Phone: g'.5-422-19.25 9a, 9b.U.S DOT Description(incEuding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Tata, 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt Not 1.UND475, Wase,Substances,e*osrve,n o.s.(PETN,ROK), 1.1GD003 (DoT-SP 1x448) (ERG 1121 EWSF 7rz z z W 3 14 Speoal Handling Instructions and Additional Information Emergency Response Phots S25-473.4205 Corract name LLNL Emergency CrrsParin F-Oaa A EWSf L9-U3. ship F3a mo t-24m - 54-e attach*dfor containernumbefs. T5. fiilEN19RATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this wnsignmenl are fully and aecurately described above by the proper shipp,ng name and are classified packaged, marked and labeledlplacarded,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,t certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenl of Consent. I certify that the waste minimization statement identified in 40 CFR 262-27(a)(if I am a large quantity generator)or(b)(if I am a small quantity ge rator)is true GeneralorslOfferors Printedltyped Name Signal A Month Day Year 5cc nt A. Graham on behatf of NNSA ,h OS 01 1 1q 16.Intemationai Shipments-� J T-- Elorn Import to U.S. ❑Export hU 5 Port of entrylexit Transporter signature(for exports only)- Date leaving U S 17 Transporter Acknowledgment of Receipt of Materials Transporter i Pnntedffyped Name Signature } Month Day Year off. a Transporter 2 Pnntedl;yped Name 5ignahlr Month Day Year H 10.Discrepancy 18a,Discrepancy Indication Space ❑ Quanbty ❑Type ❑Residue ❑Partial RejectionEl p FuI.Re t Manifest Reference Number. 1 Br:Alternate Facility(or Generator) x U.S EPA ID Number U Facility's Phone: W 18c.Signature ofAltemate Facility(or Generator) t1or.7. Da} }'ear a z 19.Hazardous Waste Report Management Method Codes(i.e,codes for hazardous waste treatment disposal,and recyding systems) 0 1. 2 3 4 20 Designated Facility Avner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted'n Item 18a PrintediTyped Name Signature Month Day Year EPA Form 6700.22(Rev.3-05) Previous editions are obsolete DESIGNATED FACILITY TO GENERATOR