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NON-HAZARDOUS 1 1.Generator ID Number 2.Page 1 0l 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 /> Generator's Phone: <br /> 6.Transporer 1 Company Name U.S.EPA ID Number <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> }fV 4 d<ci JE.I i <br /> -v*t M (`.A q6770 <br /> Facili 's Phone: Ntfl <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description No. Type Quantity W1.Nol. <br /> ¢ Hazai(kwm,Nail U0 i Fiepl#Allied,WaaM,Will <br /> ir <br /> a <br /> w <br /> w 2. <br /> r, <br /> 3. <br /> 4. <br /> 13. Special Handling Instructions and Additional Information <br /> T'r�,r , i"9 201 1- 4UH <br /> 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. <br /> Generator's/Offeror's Printed/Typed Name Signature Month Day Year <br /> 15.International Shipments <br /> � El Import to U.S. Export from U.S. Port of entry/exit- <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> ¢ Transporter 1 Printed/Typed Name Signature Month Day Year <br /> O <br /> a <br /> (/1 <br /> a Transporter 2 Printed/Typed Name Signature Month Day Year <br /> r- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Residue <br /> ❑Quantity ❑Type El Partial Rejection( ❑Full Rejection <br /> Manifest Reference Number: <br /> 17b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facili 's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 9 <br /> U <br /> w <br /> c <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 Month Day Year <br /> n USA by GC Labe <br /> 0 -9 7-6966 GENERATOR'S/SHIPPER'S INITIAL COPY <br />