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NON-HAZA`aDO 1.Generator ID Number 2.Page t of 3.Emergency Response Phone 4,Waste Tracking Numbe <br /> WASTE MAMFEST " - " 1 <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generator's Phone: - <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone. <br /> Ba 10,Containers 11.Total 12.Unit <br /> HM 91b,U.S.DOT Description No. Type Quantity Wt./Nol. <br /> 1. <br /> d <br /> ixa <br /> W <br /> z 2. <br /> W <br /> 0 <br /> 3. <br /> 4, <br /> 13. Special Handing Instructions and Additional Information <br /> 14.GENERATOR'S10FFEROR'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, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulators. <br /> generator's/Offarors Prinled7Typed Name Signature Month Day Year <br /> iJ- 15.International Shipments ❑Import to U.S. ❑Export from U.S. Port of enirylexit: <br /> Z Trans orler Si nature for exports only): Date leaving U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> Lu <br /> Transporter 1 Printedl typed Name Signature Month Day Year <br /> O <br /> a <br /> N - <br /> a Transporter 2 Printed/Typed Name Signature Month Day Year <br /> ¢ <br /> F <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ 1:1 Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Quantity yp j j <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> rai Facility's Phone: <br /> LL, 17c.&gnattne of Altercate Facility(or Generator( Month Day Year <br /> a <br /> x <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed[Typed Name Signature Month Day Year <br /> GEN ERATOR'SISHIPPER'S INITIAL 'COPY <br />