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NON-HAZARDOUS rGenerator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST <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 Comgany Name U.S.EPA ID Number <br /> r <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 /> ra <br /> Facil 's Phone: <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WtJVol. <br /> 1. <br /> cr <br /> c <br /> w <br /> Z 2. <br /> LU <br /> C7 <br /> 3. <br /> 4. <br /> 13. Special Handling Instructions and Additional Information <br /> 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, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generator's/Offeror's Printed/Typed Name Signature Month Day Year <br /> .J 15.International Shipments , <br /> I`_ ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter Signature for exports only): Date leaving U.S.: <br /> UJ 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter Printed/Typed Name Signature Month Day Year <br /> a <br /> aTransporter 2 PrinteCyped Name Signature Month Day Year <br /> H <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue Partial Rejection FIFull Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> L Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> a <br /> to <br /> w <br /> 0 <br /> 1 B.Designated Facility Owner or Operator:Certrfication of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed/Typed Name Signature Month, Day , year <br /> I I I <br /> 169-BLC-0 6 10498(Rev.9/09) COPY <br />