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NON-HAZARDOUS 1.Generator ID Number 2.Page I of 3.Emergency Response Phone 4.Waste Tracking Number ..A STE MANIFEST N1 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generators Phone: 6.Transporter I Company Name 4, U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number fn 8.Designated Facility Name and Site Address U.S.EPA ID Number K0 Facili xq s Phone: P, AM 9.Waste Shipping Name and Description 10.Containers 11.TotalN 12.Unit No. Type Quantity Wt.Nol. IN z"M 9N Qc z 2. 3. 4. 13.Special Handling Instructions and Additional Information 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. Generators/Offeror's Printed/Ted Name Signature Month Day Year 15.International Shipments Import to U.S. ❑Export from U.S. Pon of entry/exit: Transporter SignatureEor exports only): n.i.1-4—U.S.: cc 16.Transporter Acknowledgment of Receipt of Materials w — Transporter 1 PdnteclTypecl Name Signature 0 Month Day Year 9L 0 zTransporter 2 Printed/Typed Name 4 d/ Signature Month Day Year 17.Discrepancy 17a.Discrepancy Indication Space ❑Quantity ❑El Type Residue ❑Partial Rejection ❑Full Rejection rr Manifest Reference Number: 17b.Alternate Facility(or Generator) U,S.EPA ID Number M 21 Facility's Phone: ul 17c.Signature of Alternate Facility(or Generator) Month Day Year z w t7 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted In Item 17a f Printed/Typed Name Signature Month DayYear 169-BLC-0 6 10498(Rev.9/09) L:-'f-VG INITIAll. COPY