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_ . tTliilTIMM SCANNED 9314 8699 0430 0049 0968 39 NON-HAZARDOUS 1.Generator 10 Number 2.Page 1 of 3.Emergency Response Phone WASTE MANIFEST S.Generators Name and Mailing Address Lienerarerwt than mailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facili s Phone: 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit No. Type Quantity WtNaI. oC W 2 2 W 3. 4. 13.Special Handling Instructions and Additional Information 14.GENERATOR'S/OFFEftOR'S CERTIFICATION:I hereby declare that the contents of this consignment are hilly and accurately described above 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 governmental regulations. GeneratoeslOfferors Printed/Typed Name Slgnall8e Month Day Year J 15.International Shipments ❑ '- - Import to U.S. ❑Export from U:S: Part of entrylexit Transporter Signature far exports only): Date leaving U.S.: Q 16,Transporter Acknowledgment of Receipt of Materials W cc Transporter 1 PrintaNTyped Name Signature MOODay Year O CL Transporter 2 Pnntedfiyped Name Signature Month Day Year 17.Discrepancy 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. r 17b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: LO 17c.Signature of Alternate Facility(or Generator) Month Day Year w 0 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a PrintedlTyped Name Signature Month Day Year 169-B LC-0 5 11977(Rev.9/091