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cob RECE E Please print or iype. i Form Approved,OMB No,2050-O039 UNIFORM HAZARDOUS 1 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone t. anlfest TrackiNumber WASTE MANIFEST i:Q$90090= 2 1925-423-42'm 019 4 4 5 5 4 7 J J K 5.Generator s Na and Magi ' Generators Sita Address=different than mailing addressl b1v saoa I`�verrrtd>re�Lab Sete X00 on#3e W of U5 NPSA Pd2. i R1rrItt� LJxer+lllate Nlllf{iow Lala 53te$W on bekff of t$WEA etanres I=W8/L-786 UtrertrWe(CA 9451 HaVOW Rolxff rW CA VWX Generators Phone,925-W-LM ATTM Wppbv 6.Transposer 1 Company Name U.S.EPA ID Number Own Harbors Enviranmriltal SeMses Im MAM393222M 7 Transer 2 Company Name U.S.EPA ID Number C6 i^ (7x-0 '1 F `1 2--Z 6.Des nated Facility Name and Site Address U.S.EPA ID Number Clean FI3ibm La Pw-*.LR 5W 4wbpwvLm=Pratt M Sotft Lu Pcft TX 77581 Facilil�s Phone. Z81 Ji!W 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13.Waste Codes HM and Padang Group[m1 any)) Na Type Quantity UVt14ro1. 1 L NMIS,Vftde,?Loxx-y compressed,2.2[ERG 1211 LAi-LCY4.1 CY 14 P O 141 OUTS 7011 2. UN20K Waste,1411troaM Colr WC7A d.2.2[ERG 1211 Lll4tUCY41 f '7 141 OUT'S 7011 3 UN1045,Ws9te,H"e U cf>m WWSed,2.2 IERG 121]L].rt'L-Lil 25 P 141 OMI 7011 4 UN1trlZZ,M130, b4n2,2.2(ERG=1 LLNL-LCY2- 5 CY 58i 1 331 ours 8011 14.Special Handling instructions and Additional Information Errs rmcGy R prx e[ �orfa 9Z54 �oat . su .e fL-)g5� RcrOMB rs MWM LKE on YC Sea atk�d far conWiner mumbam SILL 1 CY x 24G DF,9b.Z 2 LY x 2 ea 146 LF.9b.3.2 CY it 2im 14G LF. 11"" 50--W ]9 os-(07 Wo 15 15. GENERATOR'SrOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassfied,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable Intemationaland national governmental regulations.If export shipment and i am the Primary Exporter I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identfked in 44 CFR 262.27(a)(f I am a large quantity generator)or(b)(if I am a small quantity generator)Is true. GeneraWesl0fferoes Printe0yped Name Signature - Month Day Year scan A.G-aham of bmf of the NNSA f � •� 16.International Shipments El ---�-"" import to U.S. ❑Expoq from U.S. Port of entrylexit: s Transporter signature(for exports Dnty): Date leaving US.: 17.Transporter Admm edgment of Receipt of Materials Uj 1i Transporter PnnbdWTyped Name / Fx Signature A Month Day( Year / /!! r�1V ./i4�� IJ9/�S1 ' •{rJ ` } i,/ � f{ �Y� - 4 !>� `f 1 �/ 4 Transposer 2 Prunted yped `''e�+ f / Signature f' F Month Day Year 1��,r L l ercf' ] ,� leer- =r f.r 14' 18.Discrepancy / 18a.Discrepancy indra5on Space ❑ Quantity ❑Type ❑Residua El Partial Rejection ❑Full Re}eaion Manifest Reference Number. 18b.ABemate Fa;ity jot Generator) U S EPA i D Number Facility s Phone: W 18c.Signature of Altemate Facility(or Generator) Month Day Year !a- 2t 35 19.Hazardous Waste Report Management Method Codes(i e,codes for hazardous waste treatment disposal,and recycling systems)LLI C 1 Z 3 4 2J Designated Facility Owner rata'Certification of receipt of hazardous materials covered by the manifest except as ndoin Item 189 n ypedName Signature /} Month Day Year EPA Form 87DO.22(Rev,12-17) Previous editions are obsolete. i DI= I HATED FACILITY