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NON—HAZARDOUS 1.Genereldf ID Number 77� <br /> .Emergency Response Phone 4,Waste Treckfrrg Number <br /> WASTE MANIFEST 2- +���lL <br /> 5,Generators Name and Mailing Address Generators Site Address{H diiferenl Than mailing address} <br /> < L dC YL -IN <br /> Generator's Phone: I � : <br /> 6.Transporter t Company Name U.S.EPA 10 Number <br /> r <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> B.Designated Facility Name and Site Address U.S.EPA 10 Number <br /> L L <br /> t 16 <br /> Fadi 's Phone: <br /> 9.Waste Shipping Name and 0escriplion 10.Containers 71-Total 12.Unit <br /> No, Type Quantity WI.Noi. <br /> 1- <br /> ff <br /> a <br /> rt <br /> w <br /> w 2. <br /> w <br /> 3. <br /> 4. <br /> 13-Special Handling Instruclions and Additional Information <br /> y <br /> A ] ! f rt <br /> t4.GENERATOA'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this eonsignmenl are fully and accuralely described above by the proper shipping name,and are classi5ed,packaged, <br /> marked and iabeledlplacarded,and are in aif respects in proper condition for transport according to applicable intemational and national govemmental reguiations- <br /> Generatot'slOtferoi s Printedrryped Name Signalu a Month Day Year <br /> 15.International Shipments <br /> ❑Impoa to u.5. ❑Export hom U.S- Part 01 entrylexit: <br /> x Fran rter Signature lar exports only): Dale leev n U.S.: <br /> cc 16,Transporter Ackrwwledgment of Receipt of Materials <br /> oTransporter-1 P inledTyped Name Signature Month Day Year <br /> CL <br /> aTransporter 2 Pnnledliyped Name Signature I Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue <br /> ❑ParLdl Rejection ❑Fuil Rejection <br /> 17b.AltemManilest Retetence Number- <br /> ale Facility{or Generator) U.S-EPA ID Number <br /> V <br /> LL Facititys Phone: <br /> w 17c.Signalure of Alternate Facility(or Generator) <br /> a Month Day Year <br /> z <br /> c� <br /> 18-Designaled Facility Owner or Qperalor.Certification of receipt 01 materials covered by rhe mantfesl except as noted in Clem 17a <br /> Phnied/Typed Name Signature Month Day Year <br /> 169-BLC-0 5 11977(Rev.9/D9) GENERATOR'S/SHIPPER'S INITIAL COPY <br />