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NON-HAZARDOUS WASTE MANIFEST <br /> Please.prW or type (Form designed for use on elite(12 pitch)I pewrrtur) <br /> NON-HAZARDOUS 1.Generator's US EPA ID No. Manifest 2 Pagel <br /> WASTE MANIFEST Document No. <br /> of1 <br /> 3.Generator's Name and Mailing Address <br /> 7 <br /> lrs� <br /> r f <br /> 4.Generator's Phone <br /> 5.Transporter 1 Company Name 6, US EPA ID Number A.State Transporter's ID <br /> B.Transporter 1 Phone <br /> 7.Transporter 2 Company Name 8, US EPA ID Number C.State Transporter's ID <br /> D.Transporter 2 Phone <br /> 9,Designated Facility Name and Site Address 10. US EPA ID Number E.State Facility's ID <br /> - f <br /> F.Facility's Phone <br /> 11.WASTE DESCRIPTION 12. Containers 13. 14. <br /> Total Unit <br /> No, Type Quantity Wt.Nd. <br /> a. 44 rr <br /> ef <br /> G b. <br /> E <br /> N <br /> E <br /> R <br /> A <br /> T <br /> O <br /> R d. <br /> LU <br /> F- - <br /> Q <br /> G.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above <br /> ,�lr1Y: c <br /> a <br /> N <br /> 15.Special Handling Instructions and Additional Information <br /> r <br /> Z <br /> 0 <br /> Z <br /> �l. <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 Signature Month Day Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Dale <br /> A PrintedlTyped Name, ignature Month Day Year <br /> .NS. rT�* fir. r`r --`''/'r.� i•-� .- `_--_ --,� -__ ,��� f �!i <br /> p '18.Transporter 2 Acknowledgement of Receipt of Materials Date <br /> T Printed/T ed Name Signature'� YP 9 Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 20 Facility Owner or Operator;Certification of receipt of the waste materials covered by this manifest,except as noted in item 19. <br /> I i -- Date <br /> T Printed/Typed Name Signature <br /> I j Month Day Year <br /> Y tit-v1. <br /> F-14©2002 LABELI"IASTER® (600)621-5806 www,labelmaster.com „1i16T,,, IRev, 3195 <br /> INH_ <br />