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Page 1 of 3,Emergency 7IRl.espon- FWaste Tracking Number Generator ID Number so!Phone 4.W NON-HAZARDOUS W7 "OUS T WASTE MANIFEST 5.Generator's Name and Mailing Address J Y5 'Genefator's Site Address(if different than mailing address) f 4� Generator's Phone: 6,Transporter I Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number X, 4 ,- ID 'Fac 1's 10.Containers 11.Total 12.Unit 9 1 Waste Shipping Name and Description No. Type Quantity Wt,Nol. Uj p, it 0 W A J 4. ks g WE 13. Special Handling Instructions and Additional Information 1,61 014f)11,f 14,GENERATOR'SIOFFEROR'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. Generatoes/Offero?s PdntedfTyped Name Slgnature:jr� Mont)h Day Yeqr. .j 15,International Shipments r- R Import to U.S. D Export from U.S`.' Pod of entry/exit: Z Transporter Si nature for exports only): Date leavina U. cc 16.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year 0 CL 2 Transp6fter 2 Printed/Typed Name I Signature Month 4 Orgy Year cc 17.Discrepancy Full Rejection 17a.Discrepancy Indication Space ❑F El Quantity El❑Type R Residue ElPardal Rejection Manifest Reference Number: 17b.Alternate Facility(or Generator) U.S,EPA ID Number u. Facility's Phone: 17c,Signature of Alternate Facility(or Generator) Month Day Year z gy 18.Designated Facility Owner or Operator-r.Certification of receipt of materials covered by the manifest except as noted in Item 17a PdntediTyped Name Signature Month Day Year , c6py 169-SLC-00 10498(Rev.9/09)