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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number WASTE MANIFEST I qi_J y 3 1 458 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facili 's Phone 10.Containers 11.Total 12 Unit 9.Waste Shipping Name and Description No. Type Quantity WtNol. i. O r a W z 2. W 3. (7 4. 13. Special Handling Instructions and Additional Information 14.GENERATOR'SIOFFEROR'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, marked and labelediplacarded.and are in all respects in proper condition for transport according to applicable international and national governmental regulations. Generator's10Heroes PrintedfTyped Name Signature Month Day Year 15.international Shipments ❑I^aca r^l' ❑Export from U.S Pod of entry/exit —_ Trans iter Signature for exports onl : Date leaving U.S.: cc 16.Transporter Acknowledgment of Receipt of Materials w Transporter 1 Printedrryped Name Signature Month Day Year ccO a rn r a Transporter 2 PdntedrTyped Name Signature Month Day Year 17.Discrepancy 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue El Partial Rejection ❑Full Rejection Manifest Reference Number: 17b.Alternate Facility(or Generator) U.S.EPA ID Number J U u- Facility's Phone: W 17c.Signature of Alternate Facility(or Generator) Month Day Year W a z O N W O 11 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a ted/Typed Name Signature Month Day Year rRANSPORTER 1r1 1-800.997-6368 913 7$9GG: