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NON-HAZARDOUS 1.Generator ID Number 2.Page I of 3 Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST <br /> t <br /> 5 Generatoror s Name <br /> and Mailing Address <br /> Dsrator's Site Address(K dfffereWt an mailing address) <br /> Generators Phone <br /> 6 Transporter I Company Name U.S.EPA ID Number <br /> J <br /> 7 Transporter 2 Company Name U.S.EPA-ID Number <br /> 8 Des;gn Hed Facility Name and Site Address <br /> U.S.EPA ID Number <br /> Facilis Phone: ,7 <br /> 9 Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt.Nol. <br /> 0 <br /> z <br /> 2. <br /> 3. <br /> 4 <br /> 13 Special Handling Instructions and Additional Information <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION;I hereby declare that the contents of this consignment are fully and accuratefy described above by the proper shipping name,and are classffled,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Gerierator's/Offeror's Pnnted/Typed Name Signature Month Day, Year <br /> 15 International Shipments <br /> 1:1 import to U.S. ❑Export tram U.S. Port of entry/exit: <br /> Trans rter Si nature fore rts orfPalo leaving U.S.: <br /> m16 Transporter Acknowledgment of Receipt of Materials <br /> Transporter I Printedl Typed Name Signature f� 9 1 <br /> Month Day Year <br /> z Transporter 2 Printedrryped Name <br /> Signature L Month Day Year <br /> 17 Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue El Partial Rejection El Full Rejectlon <br /> 17b Alternate Facility(or Generator) Reference Number: <br /> U.S.EPA ID Number <br /> iJ <br /> LL Facility's Phone <br /> m Signature of Alternate Facility(or Generator) <br /> Month Day Year <br /> ra <br /> IU <br /> 18 Designated Facility Owner or 6W.—ior Certification of receipt of materials covered by the manifest except as noted in hem 17a <br /> r Printed(Typed Name Signature Month Day <br /> Year <br /> 169-BLC-0 6 10498(Rev.9/09) GEN ERATOR'S/SHIPPER'S INITIAL COPY <br />