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� NON-HAZARDOUS 1.Generator ID Number =!r3.rEmergencyhone 4.Waste Tracking Number <br /> WASTE MANIFEST <br /> 5.Generator s Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generator's Phone. <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 3.Designated Facility Name and Site Address U.S.EPA ID Number <br /> i <br /> Facilit's Phone: <br /> 10.Containers 11.Total 12.Unit <br /> i 9.Waste Shipping Name and Description <br /> No. Type Quantity Wt./Vol. <br /> IX1 <br /> O <br /> Q <br /> ¢ <br /> w <br /> z 2. <br /> LU <br /> C7 <br /> 3, <br /> 4. <br /> 13. Special Handling Instructions and Additional Information <br /> I ' <br /> 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, <br /> marked and labeled 1placarde6,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generator's/Offeror's PrintedlTyped Name Sign r Month Day Year <br /> `J1 <br /> 15.International Shipments <br /> Z i ❑Import to U.S. Export from U.S. Port of entry/exit: <br /> Transoorfer Signature ifor exports only): Date leaving U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> ¢ Transporter 1 PrintedlTyped Name Signature Month Day Year <br /> a <br /> rn <br /> z Transoorter 2 Printed/Typed Name Signature Month Day Year <br /> ¢ <br /> r <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity El Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> Lu 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> ti <br /> z <br /> rn <br /> w <br /> o: <br /> i <br /> 18 Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed yped Name Signature Month Day Year <br /> 169-BLC-0 5 11977(Rev.9/09) (-r M'm RA7()I~-'S,SH!F-PER'S !�IPTIAL. COPY <br />