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f .! FNON-HAVARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Nurn NIFfEST me and Mailing Address Generators Site Address(if different than mailing address) I f Generator's Phone: 6.Transporter 1 Company Name ' I f U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number EFac!II 7FacilityName and Site Address U.S.EPA ID Number hone: r 9.Waste Shipping Name and Description 1t).Containers if.TotalF 12•Unit t No. Type Quantity Wt.Nof. Cc 1ELu - w: 2 LU # d' 3. I — 4. 13.Special Handling Instructions and Additional Information { k 1p I � 14.GENERATOR'81OFFEROR'S CERTIFICATION:l 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 labelediplacarded,and are in all respects in proper condition for transport arxotding to applicable international and national governmental regulations. Generator'SlOfferor's PrintedlTyped Name Signature Month Day Year 15 International Shipments 3 Z ❑Import to U.S. ❑Export from U.S. f 'Port of entrylaxit. Trans iter Si nature fare orfs—1— ww= f 6.Transporter Acknowledgment of Receipt of Materials Transporter 1 PdntedrTyped Name t Signature 4 I5 Month Day Year r Z Transporter 2 Prinfedlfyped Namet"^ Signature Month Day Year 17•Discrepancy tl 77a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejectino 1 ❑Full Rejection 17b.Alternate Facility(or Generator) Manliest Reference Number: U.S.EPA ID Number I nc Facility's Phone: f17c.Signature of Alternate Facility(or Generator) Z Manth Day Year [7 W - - O . 18 Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a f+ Prinfed/Typed Name Signature Month Day Year 169-BLG0 6 10498(Rev.9/09) GENERATOR'S/SHIPPER'S INITIAL COPY I