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RECEIvim <br /> liz <br /> Please print or type.(Form des ned for use on elite(12-pitch)typewriter.) Ez"i Form Approved.OMB No,2050.0039 <br /> UNIFORM HAZARDOUS 1•Generator lA Number 2,Page t of 3.Emergency Response Phone 4.Manlfhnst racking Number <br /> WASTE MANIFEST CA2990090002 1 925-423-4205 D U S }� ! 1035 JJ K <br /> 5.Generator's Name and Mailing Address Generators Site Address lA different than mal.kng address} <br /> Lawremm 11i one NvOnal Laboratory Site 309 for NNSA Lawrence Livernsore JJaiicrral Laboratory Site 300 for NNSA <br /> P.0. Box SDS 1 L—796 Livermore , CA 94551 Carrnl Hollow )load. Tracy Cal 95376 <br /> GeneratoesPhonc 925--422-1925 ATTN.Shipping <br /> 6,Transporter 7 Company Name U.S.EPA 10 Number <br /> Clean Harbors Environmef ial Services Inc. MAD0393222SO <br /> 7.Transporter 2 Company Name U.S.EPA'D Number <br /> 8.Designated Facl4ly Name and Site Address U.S.EPA 10 Number <br /> Clean Rarbors 91.jt.tnnwdlo'r. LLC CA.D380675276 <br /> 2500 West Lakem Road. Guttorlwiliow CA 931136 <br /> Faci'i, s Phone: 651-762-6200 <br /> ga 9b.U S.DOT Descrpton(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11,Tota 12.Unit 13 Waste Codes <br /> HM and Padang Group(it any}) <br /> No Type Quantity Wt.Nc' <br /> c 1'RCL NA221Z,AS,bestcf,9,In [ERG 1711 (DC7P7Z2E]8-1) CM 20 Y <br /> � 2 <br /> W <br /> 3 <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> Emei ixencV Response Phone 925—4:3—42EIi Cron:act nam L.LNL Emergency otspatch. <br /> Load No. BTLV I9--48, Shilp Doc No. 3- 2440111 . Re`erence release nurli LXE0320 on 1nb'GICQ. �? <br /> QD0300" . Min No. CHMP21316 . SJVAPCO - 4800 Enterprii Way, Nlodesto, CA 95356 . C]4.r E"E V 3 10 "s a <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described agave by the proper shipping name,and are classified,packaged, <br /> marked and labeled'placarded,and are in all respects in proper condition for transport according to applicable intemational and national govemmentaf regulations.If export shipment and.am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA AcknovAedgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b'(if t am a small quantity generator)i�true. <br /> Generatorsrbfferors PrintedrTyped Name Signatu Month Day Year <br /> Sona A Graham on behalf u; NNSA �� _ _� V� f b r rf <br /> —1 16.International Shipments <br /> F- - ❑Import to U S. EJExpon from U.S. Part of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> Ix 17.TransporerAcknou9edgmenl of Receipt of Materials <br /> Transporter 1 Prnted!Typed Name Signature Month Day Year <br /> 0Cn <br /> - Iq <br /> Q Trarsponer 2 PnntedlTyped Name / Signatures—'- Month Day Year <br /> !l <br /> 18 hscrepancy <br /> 18a.Discrepancy Indication Space QuantityType❑ yp ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 185.Alternate Facility(or Generator) U.S.EPA ID Number <br /> 1 <br /> V <br /> u Fad sly s Phone <br /> LLI 18::Signature of Alternate Facility(or Generator) Month Day Year <br /> - 11a <br /> z <br /> N19 !-azardous Waste Report Management Method Codes(i,a..codes for hazardous waste treatment.disposal,and recyrding systems) <br /> 1, 2. <br /> L + <br /> f i � <br /> 20.1wsignated Facility Owner or Operator-Certification of receipt of hazardous materials covered by the manifest except as naffed in Item 18a <br /> Prir;edrlyped Name , ('� i ! Signature Month Day Year <br /> EPA Foi 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILrrY TO GENERATOR <br />