COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

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NON-HAZARDOUS ,TE MANIFEST 1 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone4, Waste Tracking Number 9. ator's Name and Mailing Address Generator's Phone: Generator's Site Address (if different than mailing address) 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address Facility's Phone: U.S. EPA ID Number 9. Waste Shipping Name and Description 10. Containers 11. Total Quantity 12. Unit Wt.Nol. No. Type 1. 2. 3. 4. 1 ial Handling Instructions and Additional Information 14. GENERATOR'S/OFFEROR'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 labeled/placarded, and are in all respects in proper condition for transport according to applicable International and national governmental regulations. Generator s/Offeror's Printed/Typed Name Signature Month Day Year 15. International Shipments EI Import to U.S. Transporter Signature for exports only): Export from U.S. Port of entry/exit: Date leaving U.S.: 16. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year Transporter 2 Printed/Typed Name Signature Month Day Year 17. Discrepancy 17a. Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue Manifest Reference Number: ❑Partial Rejection El Full Rejection 17b. Alternate Facility (or Generator) Facility's Phone: U.S. EPA ID Number 17c. Signature of Alternate Facility (or Generator) - Month Day Year 18, Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 17a SEP 08 20?5 r r- r -ro T Printed/Typed Name Signature Month Day Year -BLC-0 6 10498 (Rev. 9/09) DESIGNATED FACILITY TO GENERATOR