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Please print or type Form Approved.OMB N 3 <br /> UNIFORM HAZARDOUS 1-Generator IDNuummW 2,Page 1 of 3.Emergency Response Phone 4.Marl�ps�Tr kflg N� <br /> WASTE MANIFEST I CA2M9=2 1 x [l�J 'J�# 536 JJK <br /> S{�dne slot s Me and Mail" ass Generato>'s Site Address(if different than mailing address) <br /> L > nc LZb 4fe'JIM(M b8W of LS WISA LAVReM LKWTri= Leh Ste BW an beard!of LIS NNSA <br /> P.Q.L3=BW L-7Q6 Lhlt! MWe CA SMI Carrel HCO"Rood Tnq CA%375 <br /> Generator's Phone: 925-W-IM ATM %g <br /> 6.Transporter 1 Company Name U S.EPA ID Number <br /> Lmeme Lhieflrwe NatlonW LaboratOry <br /> 7 Transporter 2 Company Name U.S EPA ID Number <br /> 8 Designated Facility Name and Site Address U.S.EPA ID Number <br /> LU1 Terre Lhemwom hbbcW Lab an LteFwN of L$MM CA2991=2W <br /> 711XIa E=t An LlV+E17 IM CA 9tM <br /> Facilittls Phone 925-4U-2M <br /> ga 9b U S DOT Description¢nduding Proper Shipping Name Hazard Class,ID Number, 10.Containers 11 Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(d any),. No. Type Quantity Wt VDL. <br /> ' Na3082,Hazsirdoax+ e,u 1 ad,tr.o.s.,9,411(Iro02)rE G 171] 1 TT isw G F002 <br /> o � n <br /> 135 <br /> z 2 <br /> W <br /> t, <br /> 14 Special Handling Instructions and Additional Information <br /> EmWeRM Pkvafta Nvow 92.S-4234aM C ntk+.ct f{{am UAL.Ems=►DhW&Load LLN 20-01,S-249791. <br /> COW=I Ili MdM 001=1110M <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby dedare eial the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassilled,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intematbrialand 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 EPAAeknowledgment of Consent. <br /> I certify that the waste minimization statement identified in Q CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quarD*generator)is true <br /> GeneralDeslOfferor's PrintedlTyped Name Signature Month Day Year <br /> Brade4iy Shtnl ngar, on beh&of NMA � /[3 !7 1 <br /> 16 International Shipments 41 <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only) Date leaving U.S. <br /> re 17 Transporter AdmMedgment of Receipt oI Materials <br /> LLS <br /> Transporter l P YttedrTyped Name Sig Month Day Year <br /> ,,,,� <br /> CL filet, <br /> z Transporter 2Pnmedi typed Name Sign re Month Day Year <br /> 18.Discrepancy <br /> lea Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fua Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Faci`'ty(or Generator) U.S.EPA ID Number <br /> V <br /> LL Fadityrs Phone- <br /> 0 18c.Signature of Alternate Facility(or Generator) Month Day <br /> a <br /> z <br /> y19,Hazardous Waste Report Management Method Codes if.e,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1 �A o—i--�— T. <br /> 3. 4 <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item lea A <br /> Pnntedlfyped Name Signature Month Day Year <br /> �5r'D'*K- Y.�- Ili,a 1 16 aT 19 <br /> EPA Form 8700-22(Rev.12-1T) Previous editions are obsolete, '�~ DESIGNATED FACILITY TO GENERA <br />