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r" 4.• 9 / NON.-HAZARDOUS 1.Generator ID Number 2-P1 of 3.Emergency Response Phone 4.Waste Tracking Number WASTE MANIFEST 5.Generator's Name and Mailing Address Generator's Site Address d different than mailing address Generalo!s Pmne. 6.Transporter 1 Company Name U.S-EPA ID Number 7.Transporter 2 CcmW.y Name U.S.EPA ID Number ' E.Designated Facarty Name and Site Adoress U.S.EPA ID Number Fal Phone. 10.Comaners 11.Total 12.Unit ' 9.Waste Shipping Name and Desorption No. Type Quantity WtNol. : t. 0 UJ 2. I' w tk�. t. 3. R£ 4. �s I..; 13 Special handling Instructions and Additional Information a' a 14.GENEWOR'S;OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipp ng name,and are classrfied,packaged, marked and labeledf placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. Generators,'Clferor's Printed-Typed Name Signature Month Day Year 15.mtemational Shyments ❑Import to U.S. ❑Export from U.S. Port of enuytexit: Transporter S nature lfor expons aril Date leaving U.S.: , ¢ 16 Transporter Acknowledgment of Receipt of Materials W Transporter 1 Printed/Typed Name Signature Month Day Year a a ur Signature Month Day Year a Transccrter 2 PriniedTypii Name �g ¢ H _ 7 D.screpancy M; I7a.Oscreparq Indcabon Space ❑Quantity ❑Type ❑Residue ❑Partial Resection ❑Full Rejecticn Manifest Reference Number: H 17b Atemate=_l_lity(or Generator) U.S.EPA ID Number U { {{ a Faciity s Pnone Month Da Year E: w 17c.Signature of Aliernate Fad!ity(or Generator) y {' z .: W rail 16.Designated Faccity Owner or Operator.Certification of reoeipt of materials covered by the manifest except as noted in Item 17a ' PrntedrTyped Name Signature Month Day Year , GENERATOR'S/SHIPPER'S INITIAL COPY ��,.