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0 10 'Y <br /> X3 P594 LA27 I.WJ91A <br /> Please pant or%w.fFbrm duel nod tar Mon 12 cft) ;tar. Form Ap +red.01616 No.206D.0089 <br /> UNIFORM HAZ MMA 1.GenerelorlO r I.Pepe 1 of 3.Ennerpenc 1f monss mare ma ra np Nu <br /> WASTE MANIFEST �$ 2 925-423-4205 0 0 5 8 7 0 8 8 5 JJK <br /> 6.Ganrereoes Nerve end WigAddRU ; GeneraWs Sb Address(if d1hrard then Maling sod W) <br /> Lawmnce Uvttrrstm Natksesal Labbtasnry Site 300 rorNNSAP.O.Pox908 Lawrencr Livermore Nationtsi Laboratory Site 300 rorNNSACorral Hallow <br /> J 1-726I.Warmem+A DASU Arad Tracy CA 9S176 <br /> 1 <br /> ceneniWaPhone:9 22-1925 1`TfN:SKpgjrjA <br /> S.Transporter 1 Comww me L.5.ERA IC rr„ber <br /> Tri-State MotvrTrart Co.` MOD09SOMEQ <br /> T.Tra ortar 2 Cawmy Men r US.EPA ID Number <br /> S.Dedpnetsd o^ ,and Sb Ado U.S.EPA 0 Number <br /> Clean Harbors Co{bx.LLC 1763'r Way 471 Colfax LA 71417 LA0981055791 <br /> Fadr Phone: 31$- 27-344� :+: <br /> 9e. W U.S.DOT Dearow{Indudnp Proper 9 0ft Name.Mum Clan,ID Number, 10.Contknm 11.Tdal 12.Unt 13,Wests Codes <br /> HM and IGMWW8nY)) No. Type QuarMy WLNol, <br /> 1'UNDi66r,VbSte,ArWesiaxplosive.taamm*inseirtitive,i aN 2 DM 56 P D003 <br /> (EX19W=U7)jI 998 usj POP01WI 352 <br /> X2.UN04ST,V+me.CtlaWmg bursting,plastics bonded,lLw 1 DM 16 P 0003 <br /> Cope,=(EX ExL495 7)(EX7995060008) [EiG 11.21 35 <br /> 3'RQ. rite,A ,e*osrve,Mo.s.(F=.TNT). 3-1D(RQ 1 DF 114 P D 03 <br /> 000300T 5P 1S=) [43 1121 DOP'0138-1 3+ram <br /> UNIMM*aste.t t.minted,LID(EXL99r1110" [ERG 1121 2 OF 70 P 0 3 <br /> OURDL42-I; 352 <br /> ib.Sj adell Handling Irwtrtrttdona and tlon <br /> emergency Response Phone>SF4234 2n5 Contact tttatntt!'LL.NL Emergency Dispatch.Load No.CDL19-OL Ship 005 No.5-237392. <br /> Reference relw4e number V==on invoice <br /> 15. UENERA101'i'S 0FFWWS CE tTWr-K M: I hereby dedene Ihel the caderdn of 26 rnnerpnmenl are filly and a=mtely assmixed above by the proper ship V name.and am ciassi K padaged, <br /> marked arrd Ia ed,endarefir alb iesp xis In pmpor caxkbon for transport a"dng to applxablo international and national govemmentel reWlabom R export shbm�et and I am ore Primary <br /> Exporter,I oetsy�mntenle of itris oo"Vm m oonfo m b the sermaaltheadacfred EPAAdmakiedgrnerd of Con <br /> I codify that th w�ete+r�imiratbn rteterr,abr identifred b 4D CFR 262.27{a){il I am a�quardity g )o1(bl(If I a ettuty generator)b true <br /> Generalor's*11mroft PrinWyped Name Srgn ne Mm4h Day Year <br /> Sean Garvey oil behalf arf NNSA ff-- <br /> -j 16.btitemarlcrrel Shipments ❑ImpW6' l Q U.S. LJ Export AZ US S Port of entryfexil <br /> Transporter kFxL"(for mom Orly): Date leaving U.S.: <br /> a 17.TransporterAdainladplredd Pic* fUr furs <br /> Transporter 1 !here Signature Moan Day Year <br /> a.rwtK 1 <br /> Transpater2 5ip+a4re blorm Day Year <br /> .i <br /> ta.Discrepancy <br /> 19a.Dhrnepency irrdcagorrSpaoe ❑ **fly ❑TM ❑Reekloe ❑Pedal 11.0 don ❑F.H Re)adlan <br /> W"Fest Re!ere r.NL:mbvr. <br /> 16b.Mernate Facaty(or ) U.S.EPA ID Number <br /> e� <br /> Faciiys Phone: <br /> lot Vqnawm otAwnaterwily(ar i, Morffi Day You <br /> 19 Hazedous Waste Repot Managerner►1 WWtjrCd.fi,_codas ffor�hazardora waste baslrw,deposal.and recydng syakmslca <br /> 29. nated FacWty owner or Qpereler iecelpt a+hazardovs materials co4m by dra ma a=t as now, <br /> Pdn M Y <br /> - -1 <br /> E 8700 22W. Pr*v ash am o. w. D£ IGNAT£D FACILI TO DESTINATION STATE(IF REQUIRED) <br /> 1 <br />