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RECSg� <br /> Please print or type. Form designed for use on elite(12-pftoh)lypawriter.) Farm Approved.OMB No.205M39 <br /> UNIFORM HAZARDOUS 1.Generator 13 Number Z1925-423-4205 <br /> of 3.Emergency Response Phone 4.Man tTRcklrag Number <br /> WASTE MANIFEST CA2890090002 0 5 8 7 0 7 8 JJ K <br /> S-Generators Naree and mea�Addmaa GeneraWa Site Address(d different bran maft wWresa <br /> tawlzrsQ Lrrrrmore'I+leeronal Lab Site 300 on behalf orUS NNSA I mween— Livermore National Lab Site 300on behalf of US NNSA <br /> P.O.Box 809/1-796 Livermore CA 94551 Corral Hollow RoedTmcq CA 95376 <br /> GeneratarePnane:925-422-192S ATTN:Shipping <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Environmental Services Inc. MAD0393222SO <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated FadW Name and Ste Address U.S.EPA ID Number <br /> Clean Harbors Aragpnite.U.0 11600NertlhAptusRoad Aropnite UTS4029 UTD98ISS2177 <br /> Fad sPhone: 425-9 -000 <br /> 9a. 9b•US,DOT Description Cffduft ProW Shipping Name,Hazard Class,ID Number 10 Cortteinon 11 Total 12.Unit <br /> HM and Paddrag Getup ary)) No Type ouadly WUva, 13 Waste Codes <br /> t RQ,UN343Z. Polychlorinated bfphenyls.solid.9.III(Out of service 1 DM 121 K <br /> Date].7(03/2018) (ERG 1711 DOP003D-1 751 261 <br /> z 2 <br /> 3 <br /> 4 <br /> 14.Specsal Handing Instrut6ons andAddAional information <br /> Emergency Response Phone 925-423-4z05 Contact name U.NL Emergency Dispatch.Load N APT19-1Z ship Doc No � <br /> Refereftce release number aeoWan fnvofce.QOM99342 S.a.* 'q D q5 7 I L4 D� 5�2y T y76 <br /> 15. GENERATOR'SWFEROR'S CERTIFICATION: I hereby declare that the contents of this oorngnrnent are fully and atcuratey desabed above by the proper shipping name.and am dessirmd,padwged, <br /> marked and WmIe 1placarded,and are in at respects in proem condition fa transport aaxrding to applrwble rdemauo+al and nabonat governmental regulations ff export sNpment and I am the Primary <br /> Exporter,I obesity that dot contents of 10 consignment conform to the terms of the attached EPA Admowledgmenl of Consent. <br /> I or*that the waste minimization statement identltfed in 40 CFR 26227(a)(d I am a large quardity generator,or(b)(d I am a small quan' genera bue <br /> Gensr2torsl0reroes Printedlryped Name Sgnatuna Day Y <br /> ew <br /> Scott A. Graham on behalf of NNSA <br /> J 16,International Stupmerds <br /> El Irttpart <br /> Z 1.US ❑Export ken U 5 Pat of entry,�rlJt <br /> Transporter signature(tor exports onlyi: <br /> Date,eaving U.5. <br /> 17 Transporter or Receipt of Materials <br /> OTransporter 1 P me htarrth pay Year <br /> 0. <br /> QTrans r Pnntedriyped Morrdn Day Year <br /> Jf-Leq Zk t✓, /G <br /> 1B.oisaepancy <br /> V17- <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type Residue ❑Partial Resection ❑Ful Resecion <br /> 18b.Altemate Fa Mardfest Reference Number <br /> J_ <br /> a�(����� US EPA 10 Number <br /> tJ <br /> LL Fadtity's Phone: <br /> LU 1 Bc.Signature of Alternate FaoGry(or Generator) Moro Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report M"gameo..Method Codes(Le modes for hazardous waste trea�!rnenl,dcsposal and reeyciro rystemss <br /> in <br /> 2o.Designated Fealy Ownetor Operalnr Certification of receipt of hazardous matenals covered by the mamfesl except as noted en Item-8a <br /> PnntadliM- MNa <br /> W�WQV� <br /> 5 sure Day Year <br /> EPA Farm 87 22(Rev,3 D5) Previous editions areab sole te. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />