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NON-HAZARDOUS 1.Generator ID Number 2.Page4.�Wa.teT�cklir Emergency Response Phone 4.Waste Tracking Number WASTE MANIFEST '.t A fS.Generators Name and Mailing Address Generators Site Address{if different than mailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7,Transporter LJ Company Name ,U.S.EPA ID Number r 8,Dews-ignaledFacifty Name and Site Address U.S.EPA ID Number Facid s Phone: 9.Waste Shipping Name and Description 10.Containers 11,Total 12.Unit No. Type Quantity Wt.Nol. 2. 4:. 'Sp. 13 Special Handling Instructions and Additional information 14.GENERATOR'S/OFFEROB'S CERTIFICATION.I hereby declare that the oontants 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 wridthon for transport according to applicable international and national govemmenta)regulations. Qeneratoes/Cfferors PdntecVTyped Name Signature Month Day Year 15 International Shipments ❑ Trans Olt., ureore Import to U.S. ❑Export from U.S. Pon of entry/exit, arts onl Date leavin U.S.: m 16 Transporter Acknowledgment of Receipt of Materials w cc Transporter 1 PrintediTyped Name Signature 0 Month Day Year Z Transporter 2 Printed/Typed Name Signature Month Day Year 17 Discrepancy 17a Discrepancy Indication Space ❑Quantity ❑Type 0 F..id, ❑Partial Rejection EJ Full Rejection 17b.Alternate Facility(or Generator) Manifest Reference Number. U.S.EPA ID Number Facility's Phone: � 1-7c �r.Signature of Aitemate to Month Day Year M Designated Facility Owner or Operator:Cortffication of receipt of materials covered by the manifest except as noted in Item 17a^ N.f r Vfin=Typed Name Signature Month Day, Year 109-BLC-0 6 10498(Rev.9/09) GENERATOR'S/SHIPPER'S INITIAL COPY