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WASTE MANIFEST NONHAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number 5.Generator's Name and Mailing Address Generator's Site Address(f different than mailing address) Generator's 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 WtNol. 11. O Q Lu Z 2. w O 3. i4. 13.Special Handling Instructions and Additional Information 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents 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 condition for transport according to applicable international and national governmental regulations. Generalor's/Oteroes Printed/Typep Name Signature Month Day Year J 15.International Shipments Import to U.S. ❑ ry F Elpo Export from U.S. Pot of ent /exit: Z Transporter Signature for ex ds only): Date leaving U.S.: ¢ 16.Transporter AcknoWledgment of Receipt of Materials Lu Transporter 1 Printed/Typed Name Signature Month Day Year ccO a Transporter 2 Printed/Typed Name Signature Month Day Year ¢ H 17,Discrepancy 17a.Discrepancy Indication Space ❑Quantity El Type ❑Residue El Partial Rejection ❑Full Rejection Manifest Reference Number. S 17b.Alternate Facility(or Generator) U.S.EPA ID Number - J U LL Facilitys Phone: Lu 17c.Signature of Alternate Facility(or Generator) Month Day Year Z -� w 0 16.Designated Facility Owner or Operator Certification of receipt of materials covered by the manifest except as noted in Item 17a PrintedTyped Name Signature MwNt Day Year 169-BLC-0 5 11977(Rev.9/09) GEN ERATOR'SISHIPPER'S INITIAL COPY