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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 0l 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generators Site Address(it different than mailing address) <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facifi s Phone: <br /> 9.Waste Shipping Name and Description ill.Containers 11.Total 12.Unit <br /> No. Type Quantity WtNol. <br /> 1. <br /> W <br /> W 2. <br /> 3. <br /> 4. <br /> I <br /> 13.Special Handling Instructions and Additional Information <br /> 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, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> GeneretorsrOfferors PrintedrTyped Name Signature Month Day Year <br /> J 15.International Shipments ❑Import to U.S. ❑ExP ry <br /> ort from U.S. Port of ent /exit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PnntedlTyped Name Signature Month Day Year <br /> 0 <br /> CL <br /> Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> ¢ <br /> 17.Discrepancy <br /> 17a.Discrepancy indication Space <br /> ❑Quantity ❑Type ❑Residue Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> r 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> u. Facility's Phone: <br /> W 17c.Signature of Altemate Facility(or Generator) I Month I Day Year. <br /> ti <br /> 2 _ <br /> —� <br /> N <br /> W <br /> O <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> PdntedlTyped Name Signature Month Day Year <br /> 169-BLC-05 11977(Rev.9/09) GENERATOR'S/SHIPPER'S INITIAL COPY <br />