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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste 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 /> a <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> S.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facili 's Phone: <br /> ta <br /> 9.Waste Shipping Name and Description 10.Coniners 11.Total 12.Unit <br /> No. Type Quantity Wt.Nol. <br /> 1. <br /> t= <br /> W <br /> 2 2 <br /> W <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 labeleWplacarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations. <br /> Generators/Offerors Printed/Typed Name Signature Month Day Year <br /> -1 15.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> cc 16,Transporter Acknowledgment of Receipt of Materials <br /> W <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> O <br /> IL <br /> N <br /> ¢ Transporter 2 Printed/Typed Name Signature Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity 1:1 Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 17b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> tai Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 1 <br /> wW <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 /> PrintediTyped Name Signature Month Day Year <br /> 169-BLC-0 5 11977(Rev.9/09) GEN ERATOR'S/SHIPPER'S INITIAL COPY <br />