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NON-HA2AgpOUS 1.Generator ID Number WASTE MANIFEST 2.Page t of 3.Emergency Response Phone 5.Generators Name and Morass4.Waste Tracking Number Mailing Generators Site Address(if different than mailing address) Generators Phone: 6.Transporter 1 Company Name - 5. 7.Transporter 2 Go m U.S.EPA ID Number Pany Name 8.Designated Facility Name and Site Address U.S.EPA ID Number GE 6. U.S.EPA ID Number 7 Facili 's Phone: ' 9.waste Shipping Name and Description 9. 10.Containers 1. 11.Total 12.Unit p � �r _ Type Quantity WWoI. a w Fa w 2. 3. o cc z W 4. 13, Special Handling Instructions and Additional Information 13 14.GENERA70R'S CERTIFICATION:I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. Generator wunerors Pdntedrfyped Name Signature -.r 15.International Shipments Month Day Year ~ ❑ z Trans orter Si nat Import to U.S.ure for ex orts onl ❑Export from U.S. w 16 Transporter Port of entry/exit I 14 . porer Acknowledgment of Receipt of Materials Date leavin U.S.: oTransporter 1 Printed/Typed Name a Signature rn Month Day Year Transporter 2 Printed/typed Name Z Signature Tr Month Day Year °C 1E 17.Discrepancy I F ¢ Tr 17a.Discrepancy Indication Space O Quantity a❑Type ❑ inResidue ❑Partial Rejection Z Tr Full Rejection ¢❑F F- 17b.Alfemafe Facility(or Generator) Manifest Reference Number: 1 J ci U.S.EPA ID Number 1; a Facili 's Phone: ° 17c.Signature of Altemafe Facility(or Generator) a Z aMonth Day Year I T W J ° I Q a R ° 1' 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a Printed Z /fyped Name I t7 Signature w Month Day Year ° ' ` ra:A GENERATOR'S/SHIPPER'S INITIAL COPY 11 Pi