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NON-HAZARDOUS 1.Generator ID Number 2.Page i of 3.Emergency Response Phone 4.Waste Tracking Number . <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) _ <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number 1 4 A <br /> 7.Transporter 2 Company Name U.S.EPA ID Number ... <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facili 's Phone: I <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> 1 No. Type Quantity Wt.Nol. <br /> O <br /> W <br /> Lu 2. <br /> 0 <br /> 3. <br /> 4. -------------------------- <br /> i <br /> 13. Special Handling Instructions and Additional Information <br /> 14.GENERATOR'S CERTIFICATION:)certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. 'Generator's/Dfferors Pnmed/Typed Name Signature <br /> Month Day Year <br /> 15.International Shipments <br /> 1" ❑Import to U.S. ❑Export from U.S. Port of entry/exit• <br /> z Trans orter Si nature for ex orts onl : <br /> mm 16.Transporter Acknowledgment of Receipt of Materials Date leavin U.S.: <br /> ¢ Transporter 1 Prinled/Typed Name ' <br /> 0 Signature <br /> y Month Day Year <br /> Transporter 2 Printed/iyped Name , <br /> ir Signature <br /> t— Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑ i Partial Rejection El Rejection <br /> r 17b.Alternate Facility(or Generator) <br /> Manifest Reference Number: <br /> U.S.EPA ID Number 1 <br /> v <br /> a Facili is Phone: <br /> z17c.Signature of Alternate Facility(or Generator) <br /> Month Day Year <br /> 55 <br /> w <br /> 0 <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed/Typed Name Signature <br /> Month Day Year � <br /> GENERATOR'S/SHIPPER'S INITIAL COPY <br />