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i <br /> NONHAZARDOUS 1•Generator 10 Number 2-Page 10l 3.Emergency Response Phone A,Weafe Tracking Number <br /> WASTE MANIFEST <br /> '' <br /> 5.Generator's Name and Mailing Address } ` Generator's Site Address(0 different than mailing addressy <br /> 5 <br /> 7 <br /> Generators Phone: <br /> 8.Transporter 1 Company Name <br /> U.S.EPA ID Number <br /> 1 <br /> 7-7ransportei 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address I} U.S.EPA ID Number <br /> Facrli 's Phone: Z r <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> 1 No. Type Wan* VA-fvot- <br /> a <br /> O <br /> w <br /> z 2. <br /> w <br /> cs <br /> 3. <br /> 4. <br /> 1 13-Speaat Ilandting Instructions and Additional Informalion <br /> 14.GENERATORWFFEROR'S CEFMFICATION:I hereby declare that the Contents of this consignment are fully and accuraley described above by It'e proper snipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in alt respeds in proper condition for transport according to applicable international and national govemmental regulations- <br /> Generatoris+0fferors Printed typed Name Signature Month {}ay Year <br /> 1 15,International Shipments <br /> ❑Import fo U.S. ❑Export Irom U.S. Purl o!enlrylexil: <br /> Trans rter Si nature for ex is ani Date lean U.S.: <br /> cc18-Transporter Acknowledgment of Receipt of Materials <br /> Transporler 1 PrinledlTyped Nemo Signalurs <br /> 0 Month Day Year <br /> JCL <br /> LIJ <br /> a Transporter 2 Printa fypad Name Signature Manm Day Year <br /> F <br /> 17.Discrepancy <br /> 17a-Discrepancy Indication Space <br /> ❑Gua" ❑Type ❑Residue ❑Partial Re}ection ❑Fuu Rejec,. <br /> �Aandest Relerenoe Numbec <br /> 176-Alternate Fadliy(or Generamr) <br /> U.S-EPA ID Number <br /> J <br /> U <br /> w Facility's Phone: <br /> 17c.Signalure of Alternate Fadliy{or Generator} <br /> Month Day Year <br /> a <br /> x <br /> 1 a.Designated Facility Owner or Operator:Certil cation of recgrpi of malenals covered by 1he manilesl except as muted in Ilam 174 <br /> Panted[Typed Name stgteature Month Day Year <br /> 169-BLC-0 5 11977(Rev.9109) GENERATRR'SISHIPPER'S INITIAL COPY <br />