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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number _ <br /> WASTE MANIFEST ['r0T► E t `fa 3 i S&.?'' _an Q ° <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than marling address) <br /> Id <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Numbert +� <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Desi fat Fac'ity Name an Site ss U.S.EPA ID Number <br /> RTM f ff <br /> FacifitVs Phone: <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WI.Nol. <br /> s <br /> L <br /> ° P <br /> w <br /> w t <br /> z 2. — <br /> w <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> �,�},3i'Cr#wi �^» `•���,.X{'w'ib; +f:.>;i)i'+:�"4'c ` 'Vit:W°:u�� "� . �'�'."r3�:'..",.f+�: �s'��e�a`1�1► g ''T <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 /> Generatotinth <br /> Signature MoDay Year <br /> J 15.International Shipments <br /> f— ❑Import to U.S. ❑Export from U.S. Port of enlrylexit: ' <br /> Z Trans orter Si nature for exports only): Date leaving U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> ¢ Transporter 1 Printedrryped Name Signatur ( Month Day Year <br /> z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> cc <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space El Quantity Quantity ❑Type Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> C 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> v <br /> LL Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> z <br /> w <br /> 0 <br /> 18.Designated Facility Owner or Operator:Certification of receilrt materials covered by the manifest except as noted in Item 17a <br /> PrintaVyped Name j) Signature _ Month Day /Year <br /> 169-BLC-0 5 11977(Rev.9/09j t TRANSPORTER#1 <br /> .r <br />