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�� HLL�qvl <br /> Please print or type (Form designed for use Cum(I Tpitcnj lypewn:er) Form Approved.OMB No.205MO39 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Ma <br /> nifest Tracking Number <br /> WASTE MANIFEST CA2890090002 i 1925-423-4205 JJ K <br /> 5.Generator's Name and Mailing Address Generato's Site Address{if different than mailing address) <br /> Lawren= Uvarmure Nat,anal Lataorstory Sits 300 fcr NNS.» Lawrrnm Luvrsrncra NazDnal Lab=tory Sit-- 3CD rc, rrrr�xg <br /> P.Q. Pax 009 ( L—796 Lr4_:m.=;rr CA 94551 Corral Nohow Raad. Trecy CA 95376 <br /> Generator's Phone: 3125.412-S2a AM, :Shipping <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Enyironmenta# 5er0ces Inc. MAD03932225CI <br /> 7 Transporter 2 Company Name U S.EPA ID Number <br /> 8.Designated Facility Name and Site Address US EPA ID Number <br /> Clean 14art:crs Grassy i',Aourrtsin. LI,.0 I "''9913017C8 <br /> Entzrstate 90, Ex t 41 3 m. East, 7 rr. . liartf- Or Knolls, Grassy Mauntn n 9 <br /> Facilily's Phone: 001-323-9?r30 <br /> gas 9b U S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Can' 12 Unit 13 Waste Codes <br /> HM and Packing Group(if any)) {�n N^ WI.Nol <br /> 0 1 AQC htA,2212, Asbeslo&,9,Ill [ERG 171]jrVE i i��� • <br /> Z <br /> L <br /> 14.Special Handling Instructions and Additional Information <br /> Emergency Response Phone 92,-423-420'K. Contact name LLNL Erslefgency t"nspatsh. <br /> Luad No. GR51.9-0 , 5htp Ice No. ;—237562 , fit erEat-e release number LXE017, on jr-;;o Le. <br /> Q0030W41 . Etn No CHFP20507 , 5jVAPCD - 48Da EnterprlsQ way, fwodesto, CA 95A58 <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassAed,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement iden58ed in 40 CFR 262271a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true <br /> Generators;0iferors Pnnled+Typed Name Signature Month Day Year <br /> Graham <br /> Scott A. on behalf of NNSA ,+x IIJ l 1 .:�!-? I C1 <br /> 1 16.ln!emational Sn!pments — <br /> z ❑import to US. ❑Export from U.S'. Port of entryfexitU <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Uj <br /> 7mnsporter 1 Printed Typed Name Signature Month Day Year <br /> M. <br /> a Transporter 2 PrinledfTyped Name Signature Month Day ' Ydar <br /> rY <br /> F- <br /> 16 Disr epancy <br /> 1Ba.Discrepancy Indicaton Space ❑ Quantity L_ Type ❑Residue ❑PaMal Rejection <br /> YP ) ❑Full Rejeu:Gan <br /> Manifest Relerence Number. <br /> 18b 4.emata facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> icti <br /> Facility s Phone: <br /> w 1Bc.Signature of Altemale Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i,a,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � 1. 2. 3. A, <br /> ( 1 �� <br /> 29.Designated Facility Oamer or Operator;Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a 17 j <br /> Printed/Typed Name 1 Signature , / l / Month <br /> EPA Form 8700-22(R69—.3-05) Previobs editions are obsolele. DESIGNATED FACILITY TO GENERATOR <br />