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NONHAZARDOUS i•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number WASTE MANIFEST 5.Generator's Name and Mailing Address Generator's Site Address(it 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 Facilit's Phone: 9.Waste Shipping Name and Description 10,Containers 11.Total 12.Unit � 1. No. Type Quantity W[Nol. Q UN'<'l:ite". 1 Iftl4ftl 1t s►tli ii f t'•! Q W W 2, 0 3. 4. 13.Special Handling Instructions and Additional Information 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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. Generator's/Offeroe.s Printed/Typed Name Signature ! Month Day Year 15•International Shipments ~ 1-1Z Impart to U.S. Export from U.S. Port of entry/exit; Transporter Signature for exports only): Date fent U.S.: cc 16.Transporter Acknowledgment of Receipt of Materials oTransporter 1 Prinled/Typed Name Signature a Month Day Year a Transporter 2 Printed/Typed Name Signature Month Day Year 17.Discrepancy 17a,Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Re I ❑Full Rejection 17b.Alternate Facility(or Generator) Manilest Reference Number: M U.S.EPA ID Number U tai Facifty's Phone: o H 17c.Signature of Alternate Facility(or Generator) z Month Day Year 0 0 I 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a Printed/Typed Name Signature Month Day Year 169-B LC-0 5 11977(Rev.9/09) GENERATOR'S/SHIPPER'S INITIAL COPY