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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste <br /> Tracking Number <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if 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 /> Fadli 's Phone: <br /> Contai <br /> 9.Waste Shipping Name and Description 10. ners 11.Total 12.Unit <br /> No. Type Quantity WVVol. <br /> i. <br /> W <br /> = 2. <br /> W <br /> 3. <br /> 4. <br /> 13.Special Handing Instructions and Additional Information <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby dedere that the contents d this consignment are fully and accuratey described above by the proper shipping name,and are classified,packaged, <br /> marked and label"placarded,and are in all respects in proper condition for transport according to applicable and national govementel regulations <br /> able um <br /> Gergr4loes/Merors Print"7ypgd NameSign leu Month Day Year <br /> J 15.International Shipments <br /> ❑import to U.S. ❑Expert from U.S. Pat of erdry/901: <br /> Transporter Signature for exports only): Date loft U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> ¢ Transporter 1 Printed/Typed Name Sf)heba6 Month Day Year <br /> a (_ �.— <br /> N <br /> C <br /> Transporter Printed/Typed Name Signehue Month Day Year <br /> H <br /> 17.Discrepancy <br /> 17a,Discrepancy Indication Space ❑Quanuy ❑Typo ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Mendfest Rem Number: <br /> T 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Facility's Phone: <br /> W 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 2 <br /> a <br /> N <br /> W <br /> D <br /> 16.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as rated in Item 17a <br /> Prnted/ryped Name Signature Month Day Year <br /> 169-BLC-0 5 11977(Rev.9/09) GENERATOR'S/SHIPPER'S INITIAL COPY <br />