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NON-HAZARDOUS 1•Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> PT <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing AddressGenerator's Site Address(if different than mailing address) <br /> .r <br /> Generator's Phone: f f S <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facif s Phone:'} <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description <br /> _ No. Type Quantity WtNol. <br /> R .. <br /> W <br /> z 2. <br /> W <br /> cs <br /> i <br /> 3. <br /> ti <br /> 4. <br /> 13. Special Handling Instructions and Additional Information <br /> r ' <br /> 14.GENERATOR'S CERTIFICATION:I certify the materials described above on this man est are not subject to federal regulations for reporting proper disposal of Hazardous Waste. <br /> Generator's/Offeroes Printed/Typed Name Signature Month Day Year <br /> I <br /> 15.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> i— <br /> z Transporter Sign re for exports only): Date leaving U.S.: <br /> W 16.Transporter Acknowledgment of Receipt of Materials <br /> �- Transporter 1 Printed/Typed Name Signature ; Month Day Year <br /> ¢ J. <br /> O <br /> z Transporter 2 Printed`Typed Name Signature w Monttl Day fY r <br /> ¢ r <br /> 17.Discrepancy <br /> 17a,Discrepancy Indication Space ❑Quantity ❑T ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 17b.AHemate Facility(or Generator) U.S.EPA ID Number <br /> J � <br /> U <br /> u- Facility's Phone: <br /> W 17c.Signature of Aftemate Facility(or Generator) Month Day Year <br /> a ' <br /> z <br /> cs <br /> uj <br /> W <br /> 0 <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 /> 169-BLS-C 6 10497(Rev.8/06) GENERATOR'S/SHIPPER'S INITIAL COPY <br />