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NON-HAZARDOUS 1.Generator ID Number 2,Page 1 of3.Emerge I ncy Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generators 91te Address(if different than mailing address) <br /> Generator's Phone: ZL <br /> 6.Transporter 1 Company Name U.S,I EPA ID Number <br /> T—Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facilit es Phone: 10.Containers 11.Total11 ;1,2.Unit <br /> 9,Waste Shipping Name and Description No. Type Quantity Wtivol, <br /> 1. <br /> 0 <br /> 2. <br /> 3. <br /> 13.Special Handling Instructions and Additional Information <br /> 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, <br /> r condition for transport according to applicable International and national governmental regulations. <br /> ad,and are in all respects In proper marked and labeled/placard Year <br /> Signaiure Month Day <br /> Generator's/0 farces Printe, Ped Name <br /> A <br /> —1 ❑ .'15.International Shipments 0 imf,J�o U.S. <br /> Export from U.S. ort of en4)61f- <br /> f Date leaving U,$.-. <br /> Trans orter Si nature for ex od.ply)- <br /> cc 16,Transporter Acknowledgment of Receipt of Materials <br /> LUMonth Day Year <br /> Signature <br /> Transporter 1 Printed/Typed Name,,, <br /> 0 <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> V.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> El Quantity El Type El Residue ElPartial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 17b.Alternate Facility(or Generator) <br /> u< Facility's Phone: Month Day Year <br /> a To.signature of Alternate Facility(or Generator) <br /> W <br /> z <br /> rn <br /> I B.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted In Item 17a Month Day Year <br /> Printed/Typed Name Signature <br /> INI'lFIAL COPY <br /> 169-BLC-0 6 10498(Rev.9/09) <br />