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Please print or type (Form designed for use on elite(12-pitch)typewriter) UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page i of 3.Emergency Response Phone 14.Manifest Tracking Number WASTE MANIFEST C4289001 1 19'2S-423-4205 005871056 JJ K 5 Generator's Name and 6lailing Address Generator's S to Ad tawrmrr irvermore National Laborow - NSA 7000 East Ave-L-786 L ermoreGA 7 Gerarator's Phone 5-422-1925 A e.Transperter 1 Company Name U.S EPA ID Number Lawrence Livermore National Laboratory CA2890012SM 7 Transparter 2 Company Name 8,Designated Facility Name and Site Address U-S.EPA ID Number U*rence Uvet-Tna t Natiannt laboratary.Site 30OCcrrai Hollow Rood,Tracy CA 9577E CA28901090002 FaciliysPhone: 9a. 9b.U S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers11 Total 12,Unit 13 Waste Codes HM and Packing Group(if any)( No, Type Ouantiry NJLNoI. :.UNG475, Waste,SUhstances,explosive,n.a.s.(PSTN,RDx), I.LD 'r, DM A- P W03 (E-OT-5P L54U) (ER13 1131 EVVSF 352 U, 4e �11Jr4 �. Qlrl,� a 2 c� 3 a Special Handling Instructions and Additional Information emergent esp Phon s;, Conta rzatne:LNL Ern rW,- EN pat Load A EV�SF 19-W Shtp Oor No.L-2 47ar Q1003138048 11)%3, ctw- UM310%5- Q O 0 30 8 Q r7 NS 15. GENERATOR'SIOFFEROR'5 CERTIFICATION: I hereby declare that the contents of this consignment are f0y and accurately descri ed above by the proper shipping name,and are classified,packaged, marked and tabeled.'piacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If expo[shipment and I am the Primary Exporter,l certify that the contents of this consignment conform to the terms of the attached EPAAck.vMedgment 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 quan5ly generat(r)is he. GeneratoeslCdferoes Pdnted/Typed Name Signature / Month Day Year Srott A- Graham on hehatf of NNSA �� //l �� (� lq J 16.International Shipments i- ❑Import to U.S. ❑Export from U S.y~ Port of entrylexd: z Transporter signature(for exports only); Date leaving U.S.- W 17.TraasporterAcknorMedgment of Receipt of Materials It- Transporter 1 PnntedlTyped Na /r Signature y -�C/��L/ ✓ viV� /I Q Transporter 2 PnnledlTyped Name Signature Month Day Year � f t- 19.Discrepancy 18a Discrepancy Indication Space El ou"tity ❑Type 18b Alternate Facility(or Generator) US EPA ID Number V Fadlity's Phone- W 18c.Signature of Alternate Facility(or Generator) a z U) 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU Q 1. 2, 3. 20.bes:gna:ed Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature ~~} f EPA Form`8700 22(Rev.3-05) Previous editions are obsolete. gSlGNATEDFA f ITy TO GENERATOR STATE(IF REQUIRED)