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NON-HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST <br /> 5 Generator s Name <br /> and Mailing Address <br /> Generator's Site Address(it different than mailing address) <br /> Generator's Phone <br /> 6 Transporter 1 Company Name <br /> U.S.EPA ID Number <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8 Designated Facility Name and Site Address <br /> U.S.EPA ID Number <br /> I 4' T 4 <br /> F8C111 'S Phone f�y; <br /> 9 Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WtdVol. <br /> D <br /> ! cc <br /> LU <br /> I 2 <br /> O <br /> 3 <br /> 4 <br /> 13 Special Handling Instructions and Additional Information a a <br /> t <br /> 14.GENERATOR'SMFFEROR'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 /> marked and labeledlplacarded,and are In all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> I Generatoes/OReror's Printed/Typed Name Signature ` <br /> 1 , - � Month Day Year <br /> ..r 15 international Shipments <br /> ❑ <br /> Transporter Signature(for ex rts onImport to U S ❑Export from U.S. Port of entry/eAt: <br /> l <br /> Date leaving U.S.: <br /> 16.Transporter Acknowledgment of Receipt of Materials <br /> Transport f PrinlediTyped Nama Signature <br /> OMonth Day Yea <br /> r <br /> CL <br /> Transporter 2 Pnnted/Typed Name f r t a <br /> Signature Month Day Year <br /> 17 Discrepancy <br /> I t7a.Discrepancy Indication Space <br /> ❑Ouarttrty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> I <br /> �- 17b Alternate Facility(or Generator) Manrfesi Reference Number. <br /> J U.S.EPA ID Number <br /> ' � I <br /> " rtaFacility's Phone I <br /> aa 17c Signature of Alternate Facility(or Generator) <br /> Month Pay Year <br /> z <br /> C7 <br /> I (� <br /> I18,Designated Facility Owner or Operator.Certification of recelpt of materials covered by the manliest except as noted In Item 17a <br /> PditedrTyped Name Signature Month Day Year <br /> 168-BLC-06 10498(Rev.8109) GENERATOR'S/SHIPPER'S INITIAL COPY'— <br />