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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response,Phone 1.�Wasle TrecldngNumber <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generato6 Site Address(if different than mailing address) <br /> Generator's Ph.one: 7/46.Transporter 1 Company Name ' ' <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Nirrid U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 'A' <br /> aclltysPhone: X, <br /> i <br /> t <br /> Conaners <br /> 9.Waste Shipping Name and Description 10. 11.Total 12.Unit <br /> No. Type Quantity WtiVol. <br /> 0 <br /> N'n" <br /> Cr A .......... <br /> W 2. <br /> 4. <br /> 711_A-il <br /> 13.Special Handling Instructions and Additional Information <br /> tA <br /> 'Y <br /> 14.GENERATOR'81OFFEROR'S CERTIFICATION:Thereby declare that the contents of this consignment are fully and accurately described above by the properaltipping patne;and are,classified packaged, <br /> marked and labeledlpfacarded,and are in all respects Ig proppr condition for transport according to applicable Intem3ti and hatfonq <br /> governmental regulations:' <br /> Generato( 0 eroes,Pdntbdfr ?eoName <br /> Signatuire Month Day <br /> I AT LI/ A, Year <br /> 2 <br /> � %Intemdo'naIShIpmeii(i-'__ <br /> io <br /> Impo U.S. ❑Export from U.S. Pod of ent, exit: <br /> 51 TransDort6r Signature for exports only): <br /> Date leaving U.S.: <br /> ir 16.Transporter Acknowledgment of Receipt of Materials <br /> W <br /> Transporter 1 Printed/Typed Namq,,- <br /> nth Day Year <br /> 0 nalureMo <br /> hl'J, <br /> ypeo 1'qarne <br /> Signatu <br /> IT Month Day" "Year'! <br /> 17.Discrepancyi <br /> Residue Partial Rejection ElOull Rejection17a.Discrepancy lndl&tlonSpiiiie�.. r <br /> LJ Quantity El Type ❑ <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) <br /> U.S.EPA ID Number <br /> LC Facilitys Phone: <br /> Lu 17c.Signature of Alternate Facility(or Generator) <br /> Month Day Year <br /> 0 <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted In Item 17a <br /> PrintedlTyped Name SignatureLMonth Day Year <br /> Le <br /> 169-BLC-0,6 10498(Rev.9/09) COPY <br />