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4.Waste Tracking Number <br /> 2.Page 1 of 3.Emergency Response Phone t <br /> NON-HAZARDOUS 1.Generator ID Number <br /> WASTE MANIFEST Generators Site Address(it diflerenl than mailing address) T <br /> 5.Generators Name and Mailing Address <br /> U.S.EPA ID Number 1i <br /> Generators Phone: - <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7,Transporter 2 company Name U.S.EPA ID Number <br /> 6.Designated Facilfty Name and S5 Address <br /> i <br /> 10.Containers 11.Total 12.Unit ` <br /> Facili 's Phone: Type Quantity Wt.Nol. I <br /> e.Waste Shipping Name and Descr No,iption ,l <br /> i <br /> 1. <br /> 1 cc <br /> { O <br /> Z 2. <br /> W <br /> r A 3. <br /> K�1 <br /> 4. <br /> 13. Special Handling Inuctions and Additional Information <br /> str <br /> 1 <br /> Month Day Year <br /> Signature <br /> 14.GENERATOR'S CERTIFICATION:I certify the Materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. <br /> Generator's/Offeror's Printed/Typed Name <br /> Fort of entrylexit• I l <br /> ❑Export from U.S. ' <br /> _j 15.International Shipments Ej Import to U.S. Date leavin U.S.: <br /> z Month Day Year <br /> Trans orter Si nature for exert of Receipt of Materials <br /> x 16.Transporter Acknowledgment Signature <br /> La Transporter 1 Printed/Typed Name Month Day <br /> p Signature <br /> a. <br /> z Transporter 2 PrintedlTyped Name <br /> Q <br /> Full Rejection <br /> 17.Discrepancy ❑Type Residue ❑partial Rejection <br /> ❑ <br /> 17a.Discrepancy Indication Space Quantity <br /> Manifest Reference Number. U,S.EPA ID Number <br /> 171b.Alternate Facility(or Generator) <br /> � Month Day Year <br /> U <br /> ua Facili 's Phone: <br /> w° 17c.Signature of Alternate Facility(or Generator) <br /> a <br /> z <br /> c� <br /> W <br /> O <br /> t as <br /> i6.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest exsgnaturenoted in Item 17a <br /> Month Day Year <br /> Printedtlyped Name <br /> GENERATOR'SISHIPPER'S INITIAL COPY <br />