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State of CotliforniaA-Environmental Protection Agency <br /> 'Form A oroved 0-0039(Expires 9-3094 See Instructions on hack o a <br /> ♦: ( P ) - Department of Tor' ' >ces Control <br /> Please print or type. Form designed for use on elite(12-pitch)fyp c Socram a 'La <br /> '- <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document Na 2. Page i Information in iWe RKicrs <br /> snot required by Fe <br /> WASTE MANIFEST of r <br /> 3. Generator's Name and Mailing Address <br /> 1 <br /> .ienereror,phone ) "» �� � '. - -2D <br /> Transporter 1 Company Name 6. US EPA ID Number <br /> c A21,11910101 1 25 B 4 <br /> J <br /> J 7. Transporter 2 Company Name 8. US EPA ID Number <br /> /Q <br /> U <br /> Q 9. Desi9noted Facility Name and Site Address 10. US EPA ID Number <br /> z ()S {,:! Tri-na* +ent�& ReC`t very Servi , ,.S <br /> O 1,02) c� rryesa« st3., ,:orifi jose. CA 95133 <br /> D 3 5 9 4 9 4 a 1 Q <br /> Q <br /> U 12. Containers 13. Total 14. Unit <br /> Z 11. US DOT Description(including Proper Shipping Nome,Hazard Class,and ID Number) <br /> _ No. T Quantity Wt/Vol <br /> ~ Q ` ev,stp hese!Fuel. 3. NA 1993 01 <br /> �3 G r, ip+nn( 0O 1 TT 04700 G <br /> o E <br /> 0o N b. <br /> 00 E <br /> v R <br /> d A ,p <br /> 0 T C. 3 <br /> O <br /> W R <br /> W <br /> Z d. <br /> W <br /> V ' <br /> W <br /> h <br /> CL <br /> t!9 <br /> W <br /> J <br /> Q <br /> Z <br /> ° LLNL Shipping Doc.#L-44081 ERG #27 ,'+ <br /> Z I I Job u- 151960 Reference Release # IWY0425 on -the invoice. <br /> W Wear protective clothing while handling . These materials are NOT radioactivets contaminated. <br /> J 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, - <br /> J packed,marked,and labeled,and are in all respects in proper condition for transport b highway according to applicable federal,state and international laws. <br /> Q P P P P P Y 9 aY n9 PP <br /> U <br /> If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be f <br /> J economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> Nthreat to human health and the environment; OR, if I am a small quantify generator, 1 have made a good faith effort to minimize my waste generation and select the best <br /> waste management method that is available to me and that I can afford. <br /> O Printed/Ty ed Nome Signature Month Da Year <br /> n�..h d" r .i f-- 1L.1- rr y <br /> } �:�,-.:,L,:a � _vuer,v7 hehalr utrs� >3 3 1 5 4 <br /> !Z VT 17. Transporter 1 Acknowl d ement of Receipt of Materials <br /> R <br /> v, S Printed/Td t lVO _pme g ; Signature Month Day Year <br /> W P ly <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> W R Printed/Typed Name Signature <br /> TMonth Day Year <br /> W E <br /> Q R <br /> tW 19. Discrepancy Indication Space <br /> Q F <br /> V A <br /> Z I J+ — 5 <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. .i <br /> T Printed/Typ0d N Signature,-, /` Month Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (7/92) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DISC within 30 days.) <br />