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NONHAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number WASTE MANIFEST 5.Generator's Name and Mailing Address Generators 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 pYTwwc3 t 411' 3875 Pcbbwt� I i, Facility's Phone: 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit No. Type Quantity Wt.Nol. 1. O ir fir Lu 2. C7 i 3. 4. 13.Special Handling Instructions and Additional Information Prc4twt Numbeif 537143 Dt5t:,urnerlt DW)544 I s"'t r •• j`t DO>12113/24 tJNP 14.GENERATOR'S/OFFEROR'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 labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. Generator's/Offerors Printed/Typed Name Signature Month Day Ye i i { 15.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Trans orter Si nature for exports only): Date leavingU.S.: w 16.Transporter Acknowledgment of Receipt of Materials oTransporter 1 Printed/Typed Name Signature Month Day Y a N z Transporter 2 Printed/Typed Name Signature Month Day Y t•- 17.Discrepancy 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 17b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: 17c.Signature of Alternate Facility(or Generator) Month Day Q z 0 r5 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a Printed/Typed Name Signature Month Day