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Please print or type.(Form designed for use on elite(12-pitch)typewriter) <br /> NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST ,<<t i.', 0th-;3 <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> GeneralorsPhone! F. '_` <br /> 6.Transporter 9 Company Name U.S.EPA IO Number <br /> 7.Transporter 2 Company Name U.S.EPA W Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facifty'sPttone3`ait,;�s'.�:•.r;-r�`, <br /> 9, 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WI.Nol. <br /> 1. <br /> k;a3t'S,{ a,it tR.l ,{..__ A..1,.," i' t_ 01'SJ j �'(tl _:', t}i4�, �. {.c-�., i 11A <br /> r�r <br /> D:r <br /> 0 <br /> 3 <br /> 4. <br /> 13.Special Handlirig,Inskudlons and Additional Information <br /> i'.F'ai, F sx 'y'r4 5 t 1!k'; i'tFrof'z <br /> 14. GENERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposat of Hazardous Waste, <br /> Generator's/Offerors Printed/Typed Name Signature .. Month Day Year <br /> -j 15.International Shipments1 <br /> i- ❑import to U.S. ❑Export from U.SJ Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> � <br /> 16.Transporter Acknowledgment of Receipt of Malerlafs j <br /> Transporte,:1 Printed/Typed Name ; Signature,} Month Day Year <br /> z Tra <br /> nspoder 2 Piin€edffyped Name Signature Month Day Year <br /> h <br /> 17.Discrepancy <br /> 17a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> 17c.Signature ofAltemate Facility(or Generator) Month bay Year <br /> U) <br /> 18.Designated Facility Ownar or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> PrintedfTyped Name Signature Month Day Year <br /> u <br /> 6-NHM-C-C-11 Y <br />