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NON-HAZARDOuS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number WASTE MANIFEST - 5.Generators Name and Mailing Address Geheratots�Site Address If ditferent than mailing address)Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number A ?� (. Y 7.Transporter 2 Dmpany Name US.EPA ID Number B.Designated Facility Name and Site Addres, U.S.EPA ID Number liar..4�� 1 Facili 's Phone: t&1 10.Containers 11.Tota! 12.Unit P.Waste Shipping Name and Description No. Type Quantity W1.Nol. Ir cc Lu Lu z 2 Lu c� 3. 4. 13.Special Handling Instructions and Additional Information 1 r G � 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described shove by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations. GeneratorslOSfe}rorsjPp'& yg�dplame Signature f Month Day Year 'I J 15.Intemational hipme i r ❑Import to U.S. ❑Eq.,from U.S. Port of entrylexit- z Trans orter Signature for exports only): Date leaving U.S.: cc 16.Transporter Acknowledgment of Receipt of Materials s Lu Transporter 1 PrintedlTyped Name Signature Month Day Year C a Transporter 2 Printedffyped Name `signatufe' % 'Month Day ear cc 17.Discrepancy 17a.Discrepancy Indication Space ❑ouantity ❑hype ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: F 17b.Alternate Facility(or Generator) U_S-EPA ID Number J U Facility's Phone: W 17c.Slgnature of Alfemate Facility(or Generators Month Day Year H Z w .. T 18.Designated Facihity Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in,tem 17a PrintedlTyped Name 1 1 Signature Month Day, Year 169-BLS-05 11979(Rev.9109) DESIGNATED FACILITY'S COPY j I