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qc�� NtILLIVLL) <br /> - Ptedse pft*rW&4Form_deskinedSor w=.aW1Z*ftcd)typomfi r.) _ _ Form .OMB No.2050.01339 <br /> UNIFORM HAZARDOUS 1.General"0 Nrrr" 2.Pape 1 of 3 Emergency Response Phone` 4.Manliest Tracking Nwrdw <br /> —wAs umaFw -CA289G090002 192S-4234205 - <br /> 5..GeneraWs Name Address Ceneralers She Address(If different than maifmp address) <br /> Uw—renc-e-Vo- m-one 151511 ffnl oratory Site .100 faf NNSA Latmratnq -Site -MD--rcw NMSA <br /> P.O. Boa 8081 L-786 Livermore, CA 94551 Corral Hallow Road, Tracy CA 95376 <br /> Generalor's Phone 925-422-1925 ATfN:Shipping <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Environmental Services Inc- MAD0393222SO <br /> 7 Transporter 2 Company Name US EPA ID Number <br /> 8 Designated Fauolity Name and S4eAddress U.S EPA ID Number <br /> Clean Harbors Aragonite, LLC UT09SISS2177 <br /> 11600 North Aatus Road. Aravanite UT 94029 <br /> ftcky,Phone 435-884-8100 <br /> 9a 9b U.S DOT Descrom Crndudag Proper Shipping Name.Hazard Class ID Number. 10.Containers 11 Tolat 12.Unit 13 waste Codes <br /> HM and Packing GrouP(i 3M)) No. Type Ouan6y WI.Noi <br /> 1 UN3379, Waste,Desensitized explosive,liquid,n.os.(11MX,ROX), Z DM }fir s P 0001 I F045 <br /> 3,1(DOT-SP UAM) (ERG 1Z I(DOP005AEX-1) 14 Pit 343 <br /> LU <br /> umi 2 RCL UN3437,Polychlonnated biphenyls,solid,9,111(Out of Service 1 DF 4 K <br /> Date 11r'O517016) (ERG 1711 (DOP0031--1) 261 751 <br /> 3 <br /> 4 <br /> 14.Speaal HandhN instructions end AdMdW Information <br /> Emergency Response Phone 925—423-4205 Contact name LLNL Emergency Dispatch. <br /> Load No. AP119-07, Ship Doc No. S—Z4Z6Z8 , Reference release number Z on Invoice. <br /> used small capacitors. See attached for container numbers. T49 /V z 06 7 71 <br /> 15. GENERATOR'MTEROR'S CERTIFICATIONS I hereby dedare that the contents of tlts consigramt are My and accurately desated above by the proper shipping name,and are dassified.padiaged <br /> marked and labeiedlplacarded,and are In ap respects in proper condr6on for ftgmn armrdig to appkaWe International and national pavemmantal regulations.a export shipment and i am the Primary <br /> Exporter.I certify that the contents of ties consignment conform to the terms d the attached EPAAdnowbdgment of Consent <br /> I ce"WI the waste minimization statemarrt Identified In 40 CFR 262.27(a)(t I am a large quantity generator)or(b)(NJ am a srnaii quantity generator)is true <br /> Generator sMemes PnrtedAyped Name _ Mordh Day Year <br /> !limberly A. Fugman on behalf of NNSA r 105IZ311 <br /> J 16.fntematiarra!Stripments El Import to U.S. <br /> ❑Export from U.5, of entrylexit <br /> Z Transporter signature I for exports ontyi: ate leaving U S <br /> 17,Transporter Acknowledgment of Receipt of Materials <br /> T r 1 am Month Day Year <br /> a1,14rum 146A./ i <br /> urzn <br /> 6 Transporter 2 Mtedrroed Name Moo Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.I:iscrepancy Ind"lion Space ouaitay ❑Type Residue Panes)Refection F:k Refecbon <br /> Manifest Reference Number. <br /> 1Bb.Abemate Faddy(or Generator; US EPA ID Number <br /> J <br /> U <br /> U- Fau ddys Prone <br /> W 1 Bc.Signature of Ahemate Facky("Generator) Month Day Year <br /> a <br /> z <br /> 19 Hazardous waste Report Management Method codes(i.e,codes Isar hazardous waste heatment msposal,and reryrlvg Systems) <br /> LU <br /> 2 �'A I 3. 4 <br /> "2C.Designated Facilely Owner or Operator Certification of receipt of hazardous) malenals covered by the manifest except as noW r Hem 18a <br /> PrmtedlTyped Name Souk, klorM Day Year <br /> EPA Form 8700-22(R 5) Previous editions are obsolete. DESIGNAV FACILITY TO DESTINATION STATE(IF REQUIRED) <br />