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169-BLC-O 6 10498 (Rev. 8106) _. _..L.AATORVSHIP;-cR'S INITIAL COP NON -HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Waste Tracking Number WASTE MANIFEST 5. Generator's Name and Mailing Address Generators Site Address (it different than mailing address) Generator's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Sita Address U.S. EPA ID Number Facility's Phone: 9. Waste Shipping Name and Description 10. Containers 11. Total 12. Unit No. Type Ouantrty WlNol. 1. IM O Q w Z w 2. O 3. 13. Special Handling Instructions and Additional Informatics 14. GENERATOR'S CERTIFICATION: I certify the materias described above on this mandest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. Generators`Offeroes PrintedTyped Name Signature Month Day Year Internatonal Shipments ❑ Import to U.S. ❑ P.r'5. Transporter Sicinalure Ifor exports only): Export from U.S. Port of entry, exit Date leaving US: 16. Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedrTyped Name Signature Month Day Year N Z Transporter 2 Printed/Typed Name Signature Month Day Year -- --- 17 Discrepancy 17a. Discrepancy Indication Space El❑ Ouantiry ❑TResidue Partial Rejection cti Full Reject., ype Manifest Reference Number. 17b. Alternate Facility (or Generator) U.S. EPA ID Number _ J U uu.. Facility's Phone: W 17c. Signature of Ahemate Faci'ity (or Generator) Month Day Year Q 2 C7 N W O 18 Designated Facility Owner cr Operator: Certification of receipt of materials covere3 by the manifest except a5 noted in hem 17a Printedrlyped Name Signature Month Day Year 169-BLC-O 6 10498 (Rev. 8106) _. _..L.AATORVSHIP;-cR'S INITIAL COP