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rculnu 1,477 11 7ijZ1 Please pnrtt or type.{Farm designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2454-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3,Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST rA7990090002 a 1925-d2:1-420S1005870883 JJ K 5,Generators Name and Mailing Address Generator's Site Address(if different than mailing address) Lv*mricr Livermore National Laiocrztz3ry Site 300 for NNS,. Lnwrencr Livermore Natu;.nal Lrtm"tury Sue 100 for NNEA F.0 Box GO$J L-7S6 Livermore CA 94551 Corral Haflaw Rcad.Tracy CA 45376 Generators Phone:9 25.4 22-1�125 ATrN-gLummmir 6.Transporter 1 Company Name U.S.EPA ID Number ClQan Harbors Environmental Services Inc IVIAD0393222S0 7.Transporter 2 Company Name U S.EPA ID Number 8.Designated Fad4 y Name and Sae Address U S.EPA ID Number Clown Harbors of San Jose,LLC 1021$enryessa Road San JIvie CA 95113 CADOS9494310 Facility's Phone: ,o.A c A- non ga 9b.U.S DDT Description{'including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12.Unit 13.Waste Codes HM and Packing Group(4 any)) No, Type Quantity Wl.Nol. c1'UN1192, Waste.rcttrfl lactate,3,till JERL3 129) DOPM54-1 1 P D001 1331 w z.UNL993, WPste.Flammable liquids,1`1.0-s.,3.11 jUb p2F*)LrERG P 0001U002lJ 15n 1231 G0170I15-1 212 331 3.RESfrAJE fast Contained UN1993, FlaMmable liquids-n.o s DM 9,1 P (ectamethyltnsilrxane),3,11(ERG Us] WPT)D4&-i 5121 UN1203, EVaste Gasoline,3, II [ERG LZBJ 0CP0054-1 r 7; F D001 3�1 14.Special Handling Instructions and Additional information emergency nespons,e Phone 925-4ZS-421)1, Csnta-t na:re LLNL Erre-rgtnry Cn:pat ch.Load 9-1 3-04 Ship tri:;c No. 5-2374M R&°erence release number LxEO 10q on invoice.See artached for container numbers. SJVAL=CO—4&M Enterpnse V.1ay Modesto,Ca 95356 15. GENERATOR'SIOFFEROR'S CERTIFICATION, I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are classified,packaged marked and labe!e&placarded and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I cei tty that the contents of th s consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste m;nimization statement identified in 40 CFR 262.27(a)(if I am a large quant8y generator)or(b)(if I am a small quanty qenerat-.r4true Generators?Offerors PrintedfTyped Name Signalure�C Month Daj Year Scott A. Graham on behalf a#N NSA �� ,� _ f� 0O �0 —u 16.In•`matonal Shspments '� Z ❑Import to U.S. ElExportfrom U.S Port of entryrexit: -- Transporter signature(for exports only): Date leaving U S.: 17,Transporter AckroMedgment of Receipt of Materials LU a Transporter 1 Pnntedfiyped Name Signature Month Day Year ETransporter Pnn•,edlTyped Name Signature Month Day Year CC t- 16 D'screpancy 18a,C:screpancy Irdicaft-n Space Quantity ty ❑Type ❑Residue. ❑Partial RnMc'a� ❑FuJ Re;ecton Manifest Referer ze Number. 18b A-emate Fau;ty or Generator) U-S.EPA ID Number J U LL Faa.ry's Phone w 18c 59natureotAltemateFacility'or Generator) Atonth Day Y_-ar a z 19.Krzardous Waste Report Management Method Codes(l e.,codes for hazardous caste treatment,disposai,and recycling systems) V� � Ll I I ,i I 20 7esignated Facil,ty'Owner,or Operator:Cortifeation of receipt of hazardous materials covered by the manifest except as nded in Item 113a Pnn'Mi3yped Name � 1(, .�1` I !� �� Signature _ -- T -- - —- Month I Dayl �Year EPA Form 9700-22(Rev.3-M) Pievious editldns ale obsolete. " — DESIGNATED FACILITY TO GENERATOR