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ONO - NON-HAZARDOUS 1.Generator to Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number WASTE MANIFEST 5.Generators Name and Flailing Address Generators Site Address(if different than mailing address) Generators Phone: U.S.EPA ID Number _ 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name EPA ID Number 8.Designated Fadldy Name and Site Address U.S. FaciGhys Phone: 9,Waste Shipping Name and Description 10.Containers 11.Total 12.Unit i Ppn9 No. Type Quantity Wt.Nol. 1 O w w 2 C7 3 t. d 13. Special Handling Instructions and Additional Information q �r�rr 14.GENERATOR'S CERTIFICATION:I certify,the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. Generators/Offerors Printed/Typed Name Signature Month Day Year 15.Intemat onal Shipments z El Import to U.S. ❑Export from U.S. Port of entry/exit- Transporter Si nature for exports only): Date leaving U.S.: w 16.Transporter Acknowledgment of Receipt of Materials Transponer 1 Printed/Typed Name Signature Month Day Year co Transporter 2 Printed/Typed Name Signature Month Day Year 17.Discrepancy 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 17b.Alternate Facility(or Generator) U.S.EPA ID Number _J (J LL Facili is Phone: 17c.Signature o1 Alternate Facility(or Generator) Month Day Year z a 65 W a 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a Printedlfyped Name Signature Month Day Year GENERATOR'S/SHIPPER'S INITIAL COPY