Laserfiche WebLink
N(WAZARDOUS WASTE MANOST <br /> Please print or type (Form designed for use on elite(12 pitch)typewriter) <br /> 1.Generators US EPA ID No Document <br /> Manifest 2.Page t <br /> NON-HAZARDOUS ,, Document No. <br /> WASTE MANIFEST °f <br /> 3.Generator's Name and Mailing Address <br /> 4.Generator's Phone <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.State Transporters ID <br /> 1 B.Transporter)Phone <br /> � I <br /> 7.Transporter 2 Company Name 8. US EPA ID Number , C.Slate Transporters ID <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number E.Slate Facility's ID <br /> rt <br /> " F.Facility's Phone <br /> 11?WASTE DESCRIPTION 12. Containers 13. 14. <br /> Total Unit <br /> No. Type Quantity WtNol. <br /> r b <br /> G b <br /> E <br /> N <br /> E <br /> R C. <br /> A <br /> T <br /> O <br /> W <br /> R d. <br /> Ir— <br /> U)fA <br /> jG.Additional Descriptions for Materials Listed Above H.Handling Codes for Wastes Listed Above <br /> CO .... <br /> 1 <br /> O <br /> G <br /> Q <br /> Q15.Special Handling Instructions and Addlllonal Information <br /> Z <br /> Q <br /> Z <br /> 78.GENERATOR'S CERTFICATON:I hereby certity that the contents of this shipment are fully and accurately described and are In all respects <br /> In proper condition for transport.The materiels described on this manifest are not subject to act al hazardous waste regulations. <br /> Date <br /> Printecirryped Name Signature Montt) Day Year <br /> T 17.Transporter i Acknowledgement of Receipt of Materials - 1 Date <br /> R <br /> A Prince i fyped Name Signature - Month Day Year <br /> ii <br /> p 18.Transporter 2 Acknowledgement of Receipt of Materials Data <br /> RPrinted/f <br /> T ypetl Name Signature Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <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 /> ( Date <br /> T Pdnted/Typed Name Signature Month Day Year <br /> Y <br /> F-7402002 LABELMASTFR®(800)621-5808 www.labelmaster.com m vBNrzp 04 RECYCLED FMERRev alas <br />