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NON-HAZARDOUS 1 1.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number ME, WASTE MANIFEST 5.Generator's Name and Mailing Address 'Generator`i Site Address(if different than mailing address) i"01 J_t e 001 b J -Generator's iPhone: S I 6.Transporter I Company Name U.S.EPA ID Number 7.Transporter 2 Company Name' U.S.EPA ID Number off B.Designated Facility Name and Site Address U.S.EPA ID Number J 01, 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit No. Type Quantity Wt.Nol. 0 z w 2. 3. 4. 13.Special Handling Instructions and Additional Information SSC. 14.GENERATOR'SlOFFEROR'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/Offeroes Printed/Typed Name Signature Month Day Year _J 15.International Shipments ❑ z import to U.S. ❑Export from U.S. Port of entry/exit: Transporter Signature for exports only): Date leaving U.S.: cc 16.Transporter Acknowledgment of Receipt of Materials Lu Transporter 1 Printed/Typed Name Signature Month Day Year 0 CL z Transporter 2 Printed/Typed Name Signature Month Day Year 17.Discrepancy 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 17b.Alternate Facility(or Generator) U.S.EPA ID Number ua Facility's Phone: "w 17c.Signature of Alternate Facility(or Generator) Month Day Year z 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a Printed/Typed Name Signature Month Day Year 169-BLC-0 6 10498(Rev.9/09) INFIFIAL COPY