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NON-hAZARDOUS WASTE MAN1FEtrfi <br /> Please print or type (Form designed for use on elite(12 pilch)iypewdler� <br /> NON-HAZARDOUS 1.Generater'sUSEPAIDNo. DocuManifinentNo. 2.Page 1 <br /> WASTE MANIFESTI - 01 <br /> 3.Generator's Name and Mailing Address <br /> ss , . A►vrcwr <br /> 4.Generators Phone vz fir C <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.State Transporters ID <br /> i5n t7-Of') 'C:.N V S.Transporter 1 Phone <br /> 7.Transporter 2 Company Name a. US EPA IA Number C.Slate Transparler's ID <br /> r <br /> D.Transposer 2 Phone <br /> 9.Designated Facility Name and Site Address ID. US EPA ID Number E.Slate Facility's ID <br /> VISTW.HIM ! <br /> 7'05 M JNRPM RD. F.Facility's Phone <br /> F410 VWAr GA 94311 <br /> 11.WASTE DESCRIPTION <br /> 12. Containers 13, 14. <br /> Total Unit <br /> No. Type Quantity W1.NOL <br /> 1 <br /> a. <br /> G b <br /> E <br /> N <br /> R c. <br /> A <br /> T <br /> O <br /> R d. <br /> G.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above , <br /> • <br /> F/A/F-5. Nc, omi,) <br /> C <br /> 15.Special Handling Instructions and Additional Information i <br /> i <br /> • <br /> 16.GENERATOR'S CERTIFICATION:I hereby certify that the conlenls 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 /> f <br /> Dale <br /> P(intedrryped Name Signature Month Day Year <br /> R 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R <br /> A Printed/TypAAed Name �,- � Signature Month Day Year <br /> Orfnnr79r ��'U4 rY.o-r -�" C-1��•-_M I l� -n LL3 <br /> O 18.Transporter 2 Acknowledgement of Receipt of Materials Dale <br /> T PrinledlTyped Name Signature Month Day Year <br /> E <br /> R <br /> F 19.Discrepancy Indication Space <br /> A <br /> C <br /> 1 20.Facility Owner or Operator;Certification of rece€pt of the wade materials covered by this manifest,except as noted In item 19. <br /> Date <br /> T Printedrryped Name Signature f Month Day Year <br /> Y f k k I c H 1) t_ 1• `1 .1 ( — �� !c� 1 z$ 113 <br /> F-14 02002 LABELNEASTER® (800)621-5806 w+vov.labalmasler.com 1e W„ Rev.3195 ' <br />