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NON-HAZARDOUS t Generator I number 2.Page 1 of 3.Emergency Response Phone 4.W re TrackIng Numbe <br /> WASTE MANIFEST ❑t]5 <br /> 5.G7ratr'%, a rrrwCdfling ddress Generators Sit ress if d iffe re t than re s}� <br /> ei R. <br /> B.Transpc parry� � U.S.EPA ID Numb r <br /> 7.Transporter 2 Company Name I F U.S.EPA ID Number <br /> 8.De nateAFacility Name and Sitar� U.S.EPA to Number <br /> Factli s PhoPreF <br /> 8-Waste Shipping Name and Description 10.Containers 11,Total 12.Unit <br /> No, Type Quantity Wt.Nol. <br /> LU 2. <br /> 3. <br /> 4. <br /> 13-Slaw <br /> €Handling Instructions and Additional Information <br /> k)0. <br /> 111 <br /> 0,1 'Au P4)w 44dvo <br /> 14.GEN ERATOR'SfOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and a=rately described above by the proper shipping name,and are classed,packaged, <br /> marked and iabeledrp Carded.and are in all respects in proper co dition for transport aecording to appl icabO international and nat' nal governmental regulations. <br /> Ge r ro d yped N e Sign rfl� <br /> Mor Day ear..+ 15.International Shipments TJJ ��JJ <br /> Import to 11.S. Export from U.S. Pan of enlrylexie <br /> x Trans rter Signature for exports on : Date leaving U.S.: <br /> � <br /> 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Print Name Signat M D ear <br /> 0,0' r �"{I <br /> 0. <br /> N <br /> �il t <br /> a Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> ccH <br /> 17-Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Padial Reodfon <br /> ❑Full Rejection <br /> Manifest Reference Number. <br /> 17b.Alternate Facility{or Generator} U.S.EPA ID Number <br /> zi <br /> IRV <br /> Facility's Phone: <br /> a 17c.Signature of Alternate Facility(or Generator) Mantra Day Year <br /> a <br /> x <br /> c9 <br /> LU <br /> m <br /> 0 <br /> 18,Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printedl7yped Name Signature "GENERATOR <br /> 169-BLC-05 11977(Rev.9109) DESIGNATED FACILITY <br />