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Form Approved t7M6 No.2050-0039 <br /> Rpt)US 1.Generator ID Number 2.Page 1-of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> 00069.76708 DAT <br /> Name and Mailing Address r« r Generators Site Address{if different Phan mailing address) <br /> ool nefj m'. E3d3e`d(I )13F€ i F �J�Vas H N SOON <br /> Up one: <br /> .S.EPA ID Number <br /> � parter 1 Company Name <br /> G> 11OWM7`7 <br /> C.1301 r},nsporteer 2JCompaany Niamey U.S...EPA ID Number <br /> 5 (�{��t;4!''•'v�-$�FfY��a.��Fl��P/CP�L:iRF15A®� H 4'71.��'b i�'��cF•��CiJ�IiF»Y�4� <br /> _g;Aasignaled FacNty Name and SlteAddress U.S.EPA ID Number <br /> LUC AV. <br /> r FacillysPhone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, Containers 11.TOW 12.Unit 13.Waste Codes <br /> HM andPackingGroup(if any)) No. Type Quantity WLIVol. <br /> E kX-10M['�e`•�m[s�`ikyj�1. int?V,fvg'(� c'f.+.�'s �.3°c <br /> aLU <br /> q3p e) 10 F003 <br /> 2. <br /> LLF <br /> 3. <br /> a 3 <br /> 4. 3 <br /> , <br /> 14.Special Handling Instructions and Additional Information <br /> �p€33F�i;i;€`€31�.ftzr:t1�t��Y�:S�irfa::e,�:+��zi�&':3 wd�^sGif�+r.�Gti "fy.'?#t`�'f;�k3`rE�ti�)fg"r�'f'S�65CYi��d`�it7 eiE�.d7�Std�tfit�itdf�3t��t�)i):$d$r•d�;'�[�if5��'i'v'6i��E'1��€r�1iR{YGA:'3 t,�(k27i)� <br /> 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,aryl are classified,packaged, <br /> marked and labeled/placarded,and are in all respects In proper condition for transport according to applicable intenationaiand national governmental regutaflons.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of(his consignment conform to the terms of the attached tPAAcknowledgment.of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a.Iarge quantity generator)drt{ jfl,am a*all quantity generator)is true. <br /> res/OfisrursPrintelyped Name T� Signature d;_ ,, / —Month Day Year <br /> �.. �N� r a 'r � �'• p�v.. F�3 ff { i �. <br /> j � ���'b., .. -t�� F•..i. tet: €^ .�. +,_.�.� #.,i.:�±rru,. ' . ria�t..r �• ...I. �� <br /> 16.International Shipments r. <br /> ❑Import to U.S. ❑Export from U.S. Port of en !exit: <br /> z <br /> Transporter signature(forexpods only), Date leaving U.S,: <br /> rl 17.TransporterAcknowladgment of Receipt of Materials' � <br /> LLI <br /> Transporter 1 PrintadlTyped Name Signature 1'f Month Day <br /> Year <br /> % <br /> ca <br /> � a <br /> Transporter2PdnledlTypedName Signature `_M.% Month Day Year <br /> 18.Discrepancy <br /> 1 Be.Discrepancy Indication Space ❑ quantity ❑Type ❑Partial Rejection Ll Full Rejection <br /> ❑Residue 1 <br /> Manifest Refetence Number: <br /> 18b.Alternate Facility(dr Generator) U.S.EPA ID Number <br /> U <br /> LFacilily's Phone: <br /> 18c,Signature of Alternate Facility(or Generatar) __ Month Day Year <br /> Q . <br /> z <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. C <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> Prirrtedlryped Name Signalure Month Day Year <br /> EPA Farm 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S IN(TIArL C®PT <br />