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3 <br /> Please print or type.(Form designed—for use on elite{12-1 typewriter.} <br /> "NON-HAZARDOUS 1.Generator ID Nomber 2.Page 1 of 3.Emergency Response Phone 4.Taste Tracking Number <br /> WASTE MANIFEST <br /> 5-Generator';Name and MaiiinaAddress Generator's Site Address of different than mailing address) <br /> Generator's Phone: <br /> ti.Transporter'Campany Nare U-S.EPA iD Number <br /> 7-Transporter 2 Company Name U.S.EPA ID Number <br /> E.Designated Facility Norm cnd Site Address U.S.EPA ID Number <br /> Fpdhiv's Phone: <br /> 9e 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID\umber, 10.conlainPrs 11.Total 12.Unit <br /> W and Packing Group(if any)) - leo. Typo Quantity Nol. <br /> � I <br /> a � _ <br /> d <br /> Lu <br /> LU <br /> cU <br /> 4. <br /> 13.Special Handling instructions and Additional Information <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%Vaste. <br /> Genemtar's'Oreror's Printedrfyped Name Signature Month Day Year <br /> u 15.International Shipmenis <br /> ❑Impart to U.S. ❑Export from US. Pert of enlrylexit: <br /> -- Transporter signature(for exports onti Date leaving U.S.: <br /> EX 16.TransporterAcknovrledgn-e c'Receipt of Materials <br /> LU <br /> Transporter 1 Printed, ,f =1l 3ignatur month Day Year <br /> Iimii <br /> Z Transporter 2 Prints /Typed name Sign^Ire, i,Ionlh Day Year <br /> t- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ Quantity ❑Type1 <br /> ElResidue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number, <br /> 7b.Alternale.Facility(ur Generator) U.S.EPA ID Number <br /> c� <br /> Facility's Phone: <br /> LA 17r, Signature of Alternate Facility(or Generator) Month Day Year <br /> ti <br /> 4 <br /> a� <br /> G7 <br /> C.1 <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manilost except as noted in Item 1 Ta <br /> PrintedlTyped Name Signalure Month Day Year <br /> 6-idHPJI-C-C-S 4 <br /> 6-GENERATOR'S INITIAL COPY <br />