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W <br />F— <br />N <br />V/ <br />a <br />0 <br />0 <br />M <br />a <br />N <br />a <br />Z <br />0 <br />Z <br />NON -HAZARDOUS WASTE MANIFEST <br />Please nnnl nr tvno (Form rip, imied for use on elite f12 odchl tvoewriterl <br />s <br />F-14©2002 LABELMASTERO (600)621-5808 www.labelmaster.com n�w>Hrrn Rev. 3/95 <br />IHK„ <br />NON -HAZARDOUS <br />1. Generator's US EPA ID No, <br />Manifest <br />2. Page 1 <br />WASTE MANIFEST <br />Documents o-, <br />of <br />3. Generator's Name and Mailing Address C rj <br />r., <br />4. Generator's Phone <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />A, State Transporter's ID <br />B. Transporter 1 Phone <br />7, Transporter 2 Company Name 8. US EPA ID Number <br />C. Stale 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 />yyMO, <br />F. Facility's Phone <br />IC <br />�r� �p�I�:,,� <br />ct <br />11. WASTE DESCRIPTION <br />12. Containers <br />13, <br />Total <br />14, <br />Unit <br />No. <br />Type <br />Quantity <br />Wt.Nol. <br />a. <br />d <br />! <br />G <br />b - <br />E <br />E <br />R <br />e <br />A <br />_ <br />T <br />� if,,I., <br />� <br />O <br />R <br />cL <br />G. Additional Descriptions for Materials Listed <br />H. Handling Codes for Wastes Listed Above <br />Above <br />15, Special Handling Instructions and Additional Information <br />AN <br />WM <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 />ate <br />'x <br />PrintedfTyped Name <br />Signature <br />Month <br />Day Year <br />rt <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />Date <br />A <br />NPsintedfiyped <br />Name <br />Seonalw, <br />Month <br />Day Year <br />S'/ <br />1 <br />P <br />p <br />— <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />Date <br />TPrintedfTyped <br />Name Signature <br />Month <br />Day Year <br />E <br />R <br />19, Discrepancy Indication Space <br />A <br />C <br />I <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 />I <br />I'� <br />'; % �1 i r %!C <br />Date <br />"r <br />Printedlfyped Name Signature Month <br />Day Year <br />Y <br />{ , t_ CL <br />s <br />F-14©2002 LABELMASTERO (600)621-5808 www.labelmaster.com n�w>Hrrn Rev. 3/95 <br />IHK„ <br />