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_ I <br /> i { <br /> l <br /> NON-HAZARDOUS 1 Genaraibr 10 Number 2.Page 4 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST <br /> 5,Generalor's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Gfirmoes Phone: <br /> 6,Transporler 1 Company Name U.S.EPA H]Number <br /> 7.Transporler 2 Company Name U.S-EPA ID Number <br /> ti.Designated Facility Name and Site Address U.S-EPA 10 Number <br /> '4 ,'_i '.L 4 l 'i <br /> xJ15 �,. F <br /> Facility's Phone: r '~ <br /> 9.Waste Shipping Name and Description <br /> 10.Containers 11.Total 12.Unit <br /> No. Type wamity Wt.Nol. <br /> r. <br /> a <br /> tc <br /> w <br /> z 2. <br /> w <br /> 3. <br /> 4. <br /> 13.Spectaf Handling Instructions and Additional Information <br /> 14,GENE RATOR'SIOFFEROR'S CERTIFICATION:i hereby declare Thal the torments of this consignment are fully and accurelely described above by Iia proper shipping name,and are ciassifed,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper ocnfton for Iransport according 10 applicable international and national governmental regula[lons- <br /> Generatorsl4fferor's PrintedlTyped Name Signatura <br /> Month Day Year <br /> 15.International Shipments <br /> K ElImporl to U.S. ❑Export from U-S. Port of enlrylexit <br /> Transporter Si nature for a as ofnl : Date leave U.S.: <br /> t¢ 16.Transporter Acknowledgment of Receipl of Mater als <br /> Transpor!er 1 PpntedlTyped Name Signature <br /> 4 Month Day Year <br /> a , <br /> N <br /> 2Transporter 2 Pdnt�yped Name Signature ManN Day Year <br /> a <br /> 17.Discrepancy <br /> 17a.Discrepancy Indcahon Spatz <br /> ❑Ouanhty ❑Type ❑Residue ❑Partial Reiecoon ❑FLA Reieawn <br /> Manifest Reference Number. <br /> r 17b-Allemate Fadfity(w GeneralorJ U.S-EPA ID Number <br /> Cy <br /> IQL Facilily+s Phone: <br /> F 17c.Signature of Wtemale Facriny(or Generalor) <br /> C Month Day Year <br /> 2 <br /> ii <br /> in <br /> IS-Designated Fadfity Owner or Operator.CerIA031100 of receipt Of materials covered by the nlanifesl except as noted in llem Ila <br /> PfinwTyped Name signature mom Day Year <br /> 169-BLC-0 5 11977(Rev.9109) GENERATOR'SISHIPPER'S INITIAL COPY <br />