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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 4.1itanifestTmcki Number WASTE MANIFEST i:Q$90090= 2 1925-423-42'm 019 4 4 5 5 4 7 J J K 5.Generator s Na and Magi ' Generators Site Address(H different than mailing addressl b1v saoa I`�verrrtd>re�Lab Sete X00 on#3e W of U5 NPSA Pd2. i R1rrItt� LJxer+lllate Nlllf{iow Lola 53te$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.Transporter 1 Company Name U.S.EPA ID Number Own Harbors Enviranmriltal SeMses Im MAM393222M 7 Transer 2 Company Name U.S.EPA ID Number C h i^ (fir 0 '1 F `1 2--Z 6.Des nated Facility Name and Site Address U.S.EPA ID Number Clean FI3ibm La Pw-*.LP.5W 4wbpwvLm=Pratt M Sotft Lu Pcft TX TM1 Facilil�s Phone. Z81 Ji!W 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers it.Total 12.Unit 13.4Wasie Codes HM and Packing Group[m1 any)) No Type Quantity UVt14ro1. 1 L NMIS,Vftde,?Loxx-y comprested,2.2[ERG MI LAi-LCY4.1 CY 14 P t] 141 OUTS 7021 2. UN20K Waste,1411troaM Coln WC7A d.2.2[ERG 1211 Lll4tUCY41 f '7 141 OM 7011 3 UN1045,Ws9te,H"e U CWWWsed,2.2 IERG 121]L].rt'L-Lil 25 P 141 OMI 7021 4 UN1trlZZ,M130, bsne,2.2(ERG=1 LLNL-LCY2- 5 CY 58i 1 331 ours 8011 14.Special Handling instructions and Additional Information Errs rm rGy R prx e[ rorfa 9Z54 �oa t . .e fL-)g5� RcrOMB rs MWM LKE on Y C Sea atk�d far conWiner mumbam SILL 1 CY X 24G DF,9b.Z 2 CY x 2 ea 14G DF.9b.3.2 CY it 2im 14G DF. 1i i 50--W 19 Os-(7 Coda 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 t 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 behalf of the NNSA f � •� 16.International Shipments El ---�-"" import to U.S. ❑Expoq from U.S. Port of entrylexit: s Transporter signature(for exports only): 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 Transpoter 2 Prnnted 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 ❑Ty pe ❑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 z 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 rator-Certification of receipt of hazardous materials covered by the manifest except as ndoin Item 1 Be n ypedName Signature /} Month Day Year EPA Form 87DO.22(Rev,12-17) Previous editions are obsolete. i DE I HATED FACILITY