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A a r Q <br />NON -HAZARDOUS WASTE MANIFEST <br />Please print or type (Form destgnad for use on elite f 12 pitchy typeWntor) <br />NON -HAZARDOUS 1. Generators US EPA ID No. Document No. Manifest 2. Page 1 <br />WASTE MANIFEST ai Of r <br />3. Generator's Name and Mailing Address <br />4. Generators Phone ( J0 <br />5. Transporter 1 Company Name 6. US EPA ID Number A. State Transporters ID �— <br />C D n A/ <br />B. Transporter) Phone <br />7. Transporter 2 Company Name L 1 8. US EPA ID Number C. State Transporters ID <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />11(* C AWPOW RW <br />NIO NIMM GA 04671 I <br />11. WASTE DESCRIPTION <br />a. <br />G b. <br />E <br />N <br />E <br />R <br />A <br />T <br />O <br />n <br />W <br />H <br />N <br />a_ G. Additional Descriptions for Materials Listed Above <br />Cl) <br />M <br />O <br />0 <br />a <br />N <br />15. Special Handling Instructions and Additional Information <br />r <br />Z <br />0 <br />Z <br />D. Transporter 2 Phone <br />E. State Facility's ID <br />F. Facility's Phone <br />12. Containers 13. 14. <br />Total Unit <br />No. Type Quantity Wt./Vol <br />H. Handling Codes for Wastes Listed Above <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 />qh <br />Printed/Typed Name O / e r� a <br />Signature r <br />- <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A <br />Printed/Typed Name <br />Signature <br />N <br />SC <br />;r <br />O18. <br />Transporter 2 Acknowledgement of Revel t of Materials <br />TPrinted/Typed <br />Name <br />Signature <br />E <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 <br />covered by this manifest, except as noted in item 19. <br />L <br />T <br />Y <br />Printed/Typed Name <br />Signature /y + <br />j� <br />M it R wiq rr <br />-JC® <br />F-14 m 2002 LABEtMASM ® (800) 621-5808 www.labelmaster.com <br />PRINTED ON RECYCLED PAPER pRIMTEO WITH <br />Date <br />maxim Ray Year <br />zQ KI /J <br />Date <br />Month Day Year <br />Date <br />Month Day Year <br />i <br />Date <br />Month Day Year <br />Rev. 3/95 <br />