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NON-HAZARDOUS 1.Generator 10 Number 2.Page 1 of 3.Emergency Response Phone C Waste Tracking Number <br /> WASTE MANIFEST <br /> 5.Generators Name and Meiling Address Generator's Site Address(if different than mailing address) <br /> Generator's 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 /> Facility's Phone: <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WtNol. <br /> i. <br /> p¢ <br /> Q <br /> ¢ <br /> W <br /> W 2. <br /> L7 <br /> 3. <br /> 4. <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 intematbnal and national governments]regulations. <br /> Generator's/Offerors PrintedlTyped Name Signature Month Day Year <br /> J 15.Intemational Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> r¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> O <br /> IL <br /> to <br /> Transporter 2 Printed/Typed Name Signature Month Day Year <br /> cc <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity 11 Type El 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 /> LL Facility's Phone: <br /> W 17c.Signature of Aftemate Facility(or Generator) Month Day Year <br /> a <br /> 2 <br /> to <br /> W <br /> D <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed/typed Name Signature Month Day Year <br /> 169-BLC-0 5 11977(Rev.9/09) GENERATOR'S/SHIPPER'S INITIAL COPY <br />