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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number WASTE MANIFEST 5.Generator's Name and Mailing Address Generators Site Address If 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. 1. OO w Z 2. W 0 3. 4. 13.Special Handling Instructions and Additional Information 14.GENERATOR'SIOFFEROR'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. Generators/Offerors PrinteVyped Name Signature Month Day Year J 15,International Shipments F-1 import to U.S. El Export from U.S. Port of entry/exit: Transporter Signature for exports only): Date leaving U.S.: cc 16.Transporter Acknowledgment of Receipt of Materials Lu Transpgtter 1 Printed/Typed Name Signature Month Day Year O a U) Transporter 2 Printed/Typed Name Signature Month Day Year cc2- 17.Discrepancy 17a.Discrepancy Indication Space ty ❑Type ❑ ❑ I ❑Full Rejection ❑Quantity T Residue Partial Rejection Manifest Reference Number. 17b.Alternate Facility(or Generator) U.S.EPA ID Number J U r W 17c.Signature of Alternate Facility(or Generator) Month Day Year ti 2 0 y W O 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a Printed/fyped Name Signature Month Day Year 169-BLC-0 5 11977(Rev.9/09) GENERATOR'S/SHIPPER'S INITIAL COPY