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NON&AZARDOUS WASTE MANIF T <br /> Pleas;print or type (Form designed for use on etite(12 Pitch)typewriter) <br /> NON-HAZARDOUS 1.Generators US EPA ID No. Manifest <br /> oeu hent No. 2.Page 1 <br /> WASTE MANIFEST 1 `�`� of <br /> .•3.Generators Name and Mailing Address n 1_��„1 4 v �, . � ';• "4 i s ;; �\ <br /> 22 55 .,"AiYZfbaT WRy NOFZI`aN 'EN v` . <br /> 4.Generators Phone( ) TO(kTONJCPQ _ - <br /> 5.Transporter 1 Comparty Name 6. -US EPA ID Number A,State Transporters ID ' <br /> F61Z(7QN ENV B.'Transporter 1 Phone <br /> 7.Transporter 2 Company Name - 6. US EPA ID Number - -C.Stale Transporters ID <br /> D.Transporter2'Phdne." <br /> 9.Designated Facility Name and Site Address 10. .IIUS EP41D Number E.State Facility's 1D' - ' <br /> �. - ! .; Y .•:' 1 p 4 r� 'L' �Facility's Phorii3`', � r. � ` . <br /> MGMST <br /> A.0A6MI <br /> 11.WASTE DESCRIPTION - � 1.! t..#'r'A t ,.i p )122..6ttamers'; f., . '13.' 14, <br /> Total Unit <br /> Type Quantity WtJVol. <br /> a. . <br /> E b �r e l 'N, <br /> NON Vt: '7z". bd> <br /> R e. <br /> T TT�t r o <br /> .O # _' <br /> -' G.Additional Descri{1fQtr f6rivaten'�t s ,:4 -tE`- - H.Handling Codes for wastes Usted Ahove <br /> Egof .� ; <br /> 15.Spada[Handling instructions and Addhlo_nal InformationAliW <br /> 01 <br /> 2 T <br /> 16.GENERATOR'S CERTIFICATION:I herebbyy certirythat the contents of this shipment are 1 d"accuralely'described and ere in all respects <br /> In proper condition for transport.Thematerials described on this manifest are not subject to,ederal hazardous waste regulati6ns. :�';,+ <br /> _PrirttedlTyped Name 1gna�re�, � � ,� Month Day Year . <br /> T 17.Transporter 1 Acknovrledgemem of Receipt of Materials - - - - ! Date <br /> R <br /> A Printedrryped Name _ -Signature - Month Bay Year <br /> O 16.Transporter 2 Acknowledgement of Receipt of Materials } Date <br /> TPrintedrryped Name Slgnature - Month Day Year <br /> R 1 <br /> 19.Discrepancy Indication Space <br /> F <br /> A i <br /> C <br /> 20.Facility Owner or Operator,Certification of receipt of the waste materials oovered by this manifest.ekoept as noted In Item 19. - <br /> L <br /> T Printed/Typed Name - - Signature' - Month Day Year - <br /> Y "2 fc�{ASL 1.:�H r�rf?' 1 2 9 �3 <br /> F-14 02002 LABEAAH ERS (800)621-5808 www.labolmasier.com i - rrteutrrr Rev.3195 <br />