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IOy-[SL(.;-U b 10498 (Rev. 8/06) T RA?i PZE-E u2 <br />1" 41—\chrS <br />NON•HAZAROOUS <br />1 Gene ator ID Number <br />2 Page 1 of <br />3. Emergency Response Phone4. <br />Waste Tracking Number <br />WASTE MANIFEST <br />5. Generators Name and Mailing Address <br />Generators Site Address (it ddierent than mailing address) <br />Generator's Phone: <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />Facil 's Phone: <br />9. Waste Shipping Name and Description <br />10. Gontainers <br />11. Total <br />12. Unit <br />No. <br />Type <br />Quantity <br />WtNol. <br />cc <br />1. <br />¢ <br />w <br />w <br />w <br />2. <br />0 <br />3. <br />s. <br />13. Special Handling Instructions and Additional Information <br />14. GENERATOR'S CERTIFICATION: I certdy the mafen& described above on this mandest are not subfed to federal reVauons for reporting proper dsposal of Hazardous Waste. <br />Generators'Offerors PrintediTyped Name <br />S,gnature <br />Month Day Year <br />-j <br />16. International Shipments <br />❑ Import to U.S. <br />❑ <br />Z <br />Export from U S. Port of entry: ex t <br />— <br />Transporter Signature for exports <br />Date leaving U S . <br />t¢ <br />ipt 16. Transporter Acknowledgment of Receof Maternats <br />OTransporter <br />1 Printed/Typed Name <br />Signature <br />Month Day Year <br />CL <br />U) <br />Trarspotter 2 Pr nteyTyped NameSignature <br />Idonth Day Year <br />17. Discrepancy <br />17a- Discrepancy Indication Space <br />❑ Quantity <br />❑ Type ❑ Residue <br />❑ Partial Rejection <br />❑ Full Rejection <br />Manifest Reference Number. <br />J <br />1711. Alternate Facility ((x Generator) <br />U.S. EPA ID Number <br />U <br />LL <br />Facility's Phone: <br />w <br />r <br />17c Signature of Altemaie Facility (or Generator) <br />Month Day Year <br />2 <br />w <br />0 <br />18 Designated FaoFAy Qvne o Operator. Ce tficax of r&.% ipt of materats covered by the rnandest except as Poled m Item 17a <br />P nted?yped Name <br />Signature <br />I <br />I <br />Month Day Year <br />IOy-[SL(.;-U b 10498 (Rev. 8/06) T RA?i PZE-E u2 <br />1" 41—\chrS <br />