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169-BLC-0 5 11977 (Rev. 9/09) E Ill %A 111 11 ill Z I AiN Oi 11.0- 91
1. Generator ID Number
2. Page i of
3. Emergency Response Phone
4. Waste Tracking Number
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NON-HAZARDOUS
WASTE MANIFEST
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Generator's Name and Mailing Address
Generator's Site Address (if different than mailing address)
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Generator's Phone:
6. Transporter 1 Company Name
U.S. EPA ID Number
T-A,
U.S. EPA ID Number
7. Transporter 2 Company Name
I�I II
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N.1
8. Designated Facility Name and Site Address
U.S. EPA ID Number
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Facilit 's Phone:
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10. Containers
11. Total
12. Unit
Fill
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9. Waste Shipping Name and Description
Quantity
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No.
Type
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13. Special Handling Instructions and Additional Information
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RIS/O FFEROR'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, J Jill
14. GEN ERATO
marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations.
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Generator's/Offeror's Printed/Typed Name
Signature Month Day
Year ...
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15. International Shipments ❑ import to U.S.
❑ Export from U.S. Port of entry/exit:
Transporter Signature for exports only):
Date leaving U.S.:
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16. Transporter Acknowledgment of Receipt of Materials
Day
Year
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Transport I Printed/Typed Name
Signature Month
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Transporter 2 Priped[Typed Name
Signature Month Day
Year
17, Discrepancy
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17a. Discrepancy Indication Space
Quantity
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El Type El Residue ❑ Partial Rejection Full Rejection
Manifest Reference Number:
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17b. Alternate Facility (or Generator)
U.S. EPA ID Number
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Phone:
Facility's
Month Day
Year
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17c. Signature of Alternate Facility (or Generator)
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18 Designated Facility Owner or Op Certification of receipt of materials
covered by the manifest except as not in Item 17a
Day
Month Da
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Year
fl!
Pvw'ted/Typed Name gnat
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169-BLC-0 5 11977 (Rev. 9/09) E Ill %A 111 11 ill Z I AiN Oi 11.0- 91