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� tutu <br /> — Ptedse poc Farm_deskgnedSor w=.aW1Z*ftcd)typomfi r.) _ _ _ __ Form OMB No.2050.01339 <br /> rint <br /> UNIFORM 1tUM)OU3 1.Genera"'0 Number 2.Pape794-4234205 <br /> Emergency Response Phone` 4.Manifest Trecktag Nwnber <br /> —wAs umaFw -CA289G090002 - Jj K. <br /> 5..Generabes Name AddressGenerators She Address(If ddf WL than maifmp address) <br /> -L wrrnCxZvermvre NBC ffNj�oratbry Ser 200 fae NNSA Eawreiece_`GvermorF—Naeltsnal labmirawry -Site -M0--rcw NW%A <br /> P.O. Boa 8081 1.-786 Uvermare, CA 94551 Corral Hallow Road, Tracy CA 95376 <br /> Generators Phone 925-422-1925 ATfN: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 US EPA ID Number <br /> 8 Designated Facility Name and S4e Address U.S EPA ID Number <br /> Clean Harbors Aragonite, t.lC UT09SISS2177 <br /> 11600 North Aatus Road. Aravanite UT 84029 <br /> ftcky,Phone 435-884-8100 <br /> 9a 9b U.S DOT DesaiptiaF Cindu ft Proper Shipping Name.Hazard Class ID Number. 10.Containers 11 Tolat 12.Unit 13 waste Codes <br /> HM and Padang GrOro Cd 3M)) No. Type ouan+ny wl.Nol <br /> 1 UN3379, Waste,Desensitized explosive,liquid,n.os.(11MX,RDx), Z DM }firs P 0001 I F045 <br /> 3,1(DOT-SP UAM) [ERG US](DOPOM&X-1) 14 <br /> Pit 343 <br /> LU <br /> umi 2 RCL UN3437,Polychlonnated biphenyls,solid,9,111(Out of Service 1 DF 4 K <br /> Date 11r'O517016) (ERG 1711 (DOP0031-1) 261 751 <br /> 3 <br /> 4 <br /> 14.Speaal HandhN instructions end AdMdW Information <br /> Emergency Response Phone 925—423-4205 Contact name L(NL Emergency Dispatch. <br /> Load No. APT19-07, Ship Doc No. S-14257 , Reference release number Z on Invoice. <br /> used small capacitors. See attached for container numbers. SQ M07,06 7 71,97, <br /> 15. GENERATOR'MTEROR'S CERTIFICATIONS I hereby dedare that the contents of this consignment are My and accurately described above by the proper shipping name,and are dassified.padiaged <br /> marked and labeiedlplacarded,and are In ap respects in proper condition f'ftgmn armrdng to appkaWe International and national pavem mental reguations.n export shipment and i am the Primary <br /> Exporter.I certify that the contents of this consignment conform to the tams d the atladred EPAAdnowbd9ment of Consent <br /> I ce"nut the waste mnimrzanon sratemant Identified In 40 CFR 262.27(x)rd I am a Large quantity gnerator)or(b)Ott am a amaii quantity generator)is true <br /> Generalor+sMemes Pm*nyped Name _ Modh Day Year <br /> !limberly A. Fugman on behalf of NNSA r 105 1 Z31 1 <br /> J 16.fntematiarra!Stripments <br /> El Import to U.S. <br /> ❑Export from U.5, of entrylexit <br /> Z Transporter signature I for exports orntyi: ate Leaving U S <br /> 17,Transporter Acknowledgment of Rea=of MAA* <br /> T r 1 am Month Day Year <br /> a1,14rum 0612702119 <br /> 6 Transporter 2 Mtedrroed Name Mornh Day Year <br /> H <br /> 18.Oisaepancy <br /> 18a.I:iscrepancy Indrealson Space Ouaitay ❑Type Residue Parte]Refection F:k Ralecbon <br /> Manifest Reference Number. <br /> 1Bb.Altemate Faddy(v Generator; US EPA ID Number <br /> J <br /> U <br /> U_ Fapldys Prone <br /> W 1 Bc.Signature of Anemate FaaThy('Generator) Month Day Year <br /> a <br /> z <br /> 19 Hazardous waste Report Managemen"Method codes(i.e,codes Isar hazardous waste treatment msposaL,and reryrlvg systems) <br /> LU <br /> 2 I' i)I 3. 4 <br /> IL <br /> Designated.Designated Facility Owner'Operator Certirxabon of receipt of hazardousmalenals covered by the manifest except as noted r Clem 18a <br /> PrimedlTyped Name Souk, klorM Day Year <br /> EPA Form 8700-22(R 5) Previous editions are o6aotete. <br /> DESIGNAV FACILITY TO DESTINATION STATE(IF REQUIRED) <br />