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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 r <br /> ),I t <br /> 5.Ge tor's Name and►M�aiiling Address Generators Sitey Address(if�diifferentt than mailing address) s +psi <br /> Mt. <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Numbei <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 6.Designated Facility Name and Site Address U.S.EPA ID Number <br /> V1. a C"1 aF! R S��$""� r <br /> Facility's Phone: <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit 4 <br /> No. Type Ouantity Wlivol. <br /> 1. <br /> cc t �y, 1fi+}► <br /> 0 7C U <br /> *�. !Y*.i/.�`ttR ..,w..•max.. (i,I(,�1, � * fit <br /> W <br /> z 2 <br /> W <br /> 0 <br /> 3. <br /> 4. ' <br /> 13.Special Handling Instructions and Additional Information 't\ <br /> lit U <br /> ���t: �f'�`.s"�. .�€�f.�J�-e l�?r�t��'a :�"�.s"1��"t"u,,., �a G���'1+�3^�, �t�,•e rt��[.;� � .,,�./*r L 7A :t.'trx"..�`.�'�.�L'si�tM-CX­3I'1riS <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 /> Generato(slpfferor s PSntedlTyp� me:.Na , , { , Signature�-/ �-'f Month Day Year <br /> Or <br /> lA, 2 fat3�`• . �t[�c'f <br /> J15.International Shipments ►`./ <br /> i- ❑Import to U.S. ElExport from U.S. Port of entrylexit: <br /> z Transporter Signature for exports only): Date leavingU.S.: <br /> cc 16.Transporter Acknowledgment of Receipt of Materials a <br /> ►- Transporter 1 PrintedlTyped Name Signature Month Day Year <br /> Transporter 2 Printedffyped Name Signature Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ ❑Type Quantity yp ❑Residue ❑Partial Refection ❑Full Rejection a <br /> Manifest Reference Number: <br /> r 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ut. Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> d <br /> 2 <br /> 18.Designated Facility Owner on Operator.Certification of receipt¢f materials covered by the manifest except as noted in Item 17a <br /> Printed/Typed Nam' r ` t( j Signature Month r Day Year <br /> t •i t t } 1 tS f r <br /> 169-BLC-0 5 11977(Rev.9/09) r TRANSPORTER#1 <br />