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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 - <br /> 5.Generators Name and Mailing Address Generator's Site Address(ff different than mailing address) <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name _— s - <br /> U.S.EPA ID Number <br /> 8,Designated Facility Name and,Site.Address — U.S.EPA ID Number <br /> Facil' 's Phone: <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> - -- No. Type Quantity WIJVoI. <br /> - -_ — <br /> ¢ ` <br /> L <br /> i <br /> 4. <br /> 13. Special Handling Instructions and Additional Information <br /> 14.GENERATOR'S CEft fl."GATICr: :certify the materials described ahove oc:his manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. <br /> Gene,ator'slOKeror' 'intev'Typed ivarr r I Signature — Month Day Year <br /> J 15.InternationalShipmOn's _—��-- <br /> Z r-1 Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Tr SRq ar.$i nature(for exports only): _ _ Date leaving U,S•. <br /> ¢ 16 ransporter Acknowledgment of Receipt of Materials <br /> C Transporter 1 Printe�Typed Name Signature Month Day Year <br /> a <br /> pZ Transporter 2 Prinded/Typed Name _ Signature — Month Day Year <br /> 17.DisctApancy <br /> 17a Dwrepanoy Irdcation Space <br /> ❑Quantity —❑Type L J Residue ❑Partial Rejection ❑Full Rejection <br /> __.- Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) �� U.S.EPA ID Number <br /> V <br /> a Facility's Phone: <br /> w 17c.Signature of Aftemate Facility(or Generator) <br /> a I I Month I Day I Year <br /> —-- - -. <br /> ; w <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a r <br /> Printed/Typed Name Signature Month Day Year I , <br /> t <br /> 169-BLS-C 5 11979(Rev.8/06) GENERATOR'S/SHIPPER'S INITIAL COPY <br />