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NON-HAZARDOUS 1 1-General`ID Humber 2.Page 101 3-Emergency Response Phone 4. ate Tracking Humber <br /> WASTE MANIFEST <br /> 5-Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Generators Phone; f <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Tratspader 2 Company Name <br /> U.S-EPA ID Number <br /> 8.DBsignated Facility Name and$i[B Address U.S.EPA ID Number <br /> Facafi s Phone: <br /> 9-Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> � WtNOE. <br /> No. T Ruantily <br /> 1, <br /> tt <br /> a <br /> w <br /> 2 2- <br /> Lu <br /> L'S <br /> 3. <br /> 4. <br /> 13,Special Handling insiructons and Additionat Information <br /> r, 14.GENERATOR'SIOFFERDR'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 labeled+placarded,and are in all respects in proper condNxi for transport according 10 applicable international and natrord govemmetiW mgulatiors, <br /> Generatorsl0fferors Pnnted+Typed Name Signature Idonih Day Year <br /> _ 15.fntemdli0nal Shipments ❑Impart to U.S. ❑EzpoA from U.S. Pon of enlrylexit: <br /> Transporter Signature for exports only): Dale leaving U.S.: <br /> rr 16.Transporter Acknowledgment of Receipt of Malerials <br /> Transporter 1 Prinledrfyped Name Signature Mwith Day Year <br /> O <br /> t N <br /> a Transporter 2 Pdnte&Typed Name signalwa Monty Day Year <br /> F <br /> 17.Discrepancy <br /> 17a-Discrepancy Indicalion Space <br /> ❑Quant ty ❑Type ❑Residue ❑Partial rection ❑Full Rejection <br /> Menl esl Aelererlce Number: <br /> 17b.A[terrlate Facility(or Generator) U.S.EPA ID Number <br /> 1' J <br /> II u <br /> u Facility's Phone: <br /> w 17c.Signature of Altemale Facility(or Generator) M010 Day Year <br /> a <br /> x <br /> cs <br /> IS.Migna[ed Facility Canner or operator:Certificalion of rewl of malenals covered by IN manitesl except as rested in llem 17a <br /> Prntedliyped Mame Signature Month Day Year <br /> 169-8LC-0 5 17977(Flev,9109) GENERATOR'S1SHIPPER'S INITIAL COPY <br />