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Pease print or type.(I'm designed for use on elite(12-pitch)typk,,,jb,,) <br /> t U1IF0RUS 1."_wJDNub, <br /> Form Approved.OMB No.20.140039 <br /> WASTE 'e,.7 or 3 7eTy ResoreaPhone 4. i"t Ticking Number <br /> 015384411 JJK <br /> Generatoes phm, <br /> 6.Transporter I Company Name <br /> 7.Transpoder2 Company Nam <br /> k. ('.cc Ff. <br /> 1.Niamey <br /> 8.Pesigmaled Facirity Nam and S"7. <br /> g U.S.EPA ID Number <br /> C. <br /> Faciiii Phone. Irk <br /> 9a, 9b.U.S.DOT Description(Inducing Proper Shuppi J <br /> HM and Packing Group(it ri ng Nam.Hazard Class ID Number, 10.Containers, it.TOW 12.Unit <br /> I No. Type Quantity wuvol. 13.Waste Codes <br /> r) <br /> LU <br /> LD <br /> 3. <br /> 4. <br /> 14.Spedj Handing Instructions NMSJ UAL H Ty <br /> 15, GENEWDsr IFFEROWSCER11RCATION: declare bat 1nf r <br /> marked and lateledliplecarded.and am in M respects in proper oundifion for tmnspW a of bit consignment are,fully and accuumbely deacribed alb�by the,proper shipping numne,and are dassilied.packaged, <br /> according m appkable International and rational 90"Wountal regulations.If export shipirrent and I am the Primary <br /> I EkpodeF'1 ou"y gas the contents of the consignment conform to the term at the attached EPAAckuwaledgment of Consent. <br /> car*that the aceste minimization statement identified in 40 CFR 26217(a)(If I am a Large quantity L fifliffre-Stnal quarbly generator)is true. <br /> Ger,arramesOffemes Primid/Typed Nam— S 7--: �- Mmth Day yes, <br /> -� //"- I--, "1-6: " J q. <br /> p. <br /> 16.International Shonsents, <br /> LI Import to U.S. ❑Export from U.S. Pont of entry/exit <br /> Tiransposter signature(for exports only): Dars,leaving U.S.: <br /> W 17.Transporter Acknomeogreerst of Receipt of Materials <br /> L&I <br /> Transporter 1 Printed/Typed Nam Signature Month Day <br /> Yen <br /> It Traremome 2 PrintedfTyped Nam Signature Month Day Year <br /> 18.Discrepancy <br /> itia,Discrepancy Indicator Space El oushlity, 1:1 Type EIResidue El Partial Rejection ElFull Rejection <br /> 18b,Afternade Facility(or Generator) U.S. <br /> Reference Number. U.S.EPA ID Number <br /> Ow 18,Slii..hersotAfternalafFeciW(orGenerator) Month Day year <br /> so 19.Hazardous Waste Repart Managernang Method Codes(le,codes for hazardous waste smatruent,disposal,and recycling system) <br /> w <br /> 1 1 2. 3, 4. <br /> I020.Designated!Facility Owwr or Operator:Certhi ofmcsipl of hazardous materials covered by the manifest except as Wed in Item 18a — <br /> Printedi Nam Signature Day YearEPA Fam 870422(Rev.3-05) Previous edftims are obsolete. GENERATOR'S INITIAL COPY <br />