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G <br />E <br />N <br />E <br />R <br />A <br />T <br />O <br />R <br />W <br />H <br />N� <br />a <br />Cl) <br />M I <br />0 <br />QI � <br />N <br />a <br />Z <br />0 <br />z <br />*-HAZARDOUS WASTE Mf 'FEST <br />Gf=c0n <br />NON -HAZARDOUS <br />' WASTE MANIFEST <br />1. Generator's US EPA ID No. <br />Manifest y.. <br />Document No. NH R.> bn <br />2. Page 1 <br />of 1 <br />3. Gel�rator's Name and Mailing Address <br />I , <br />4. Generator's Phone ) <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />Date <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />A. State Transporter's ID <br />B. Transporter Phone <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />I <br />C. State Transporter's ID <br />D. Transporter 2 Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />E. State Facility's ID <br />F. Facility's Phone <br />11. WASTE DESCRIPTION <br />12. Containers <br />No. Type <br />13. <br />Total <br />Quantity <br />14. <br />Unit <br />Wt.Nol. <br />a. <br />Date <br />T <br />T d N <br />Printed/ypeame <br />Signature <br />b. <br />E <br />Month Day Year <br />C. <br />d. <br />F <br />G. Additional Descriptions for Materials Listed Above <br />is <br />H. Handling Codes for Wastes Listed Above <br />15. Special Handling instructions, and Additional Information <br />16. GENERATOR'S CERTIFICATION: I hereby certify that the contents of this shipment are fully and accurately described and are in all respects <br />in proper condition for transport. The materials described on this manifest are not subject to federal hazardous waste regulations. <br />Date <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />Date <br />A <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />N <br />P <br />Q <br />R <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />Date <br />T <br />T d N <br />Printed/ypeame <br />Signature <br />E <br />Month Day Year <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />1 <br />20. Facility Owner or Operator. Certification of receipt of the waste materials covered by this manifest, except as noted in item 19. <br />L <br />_ <br />Date <br />T <br />Pdntecu Typed Name Signature <br />Y <br />Month Day Year <br />-I <br />