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� . N4fARDOUS WASTE=MANl�eS. <br /> Please printi or type a'. (Form designed for use a_n eMte,(12 pitch?typewnleF)' <br /> 1..1 A p _ - - :Manifest :2.�Page 1 - <br />_ <br /> NON-HAZARDOUS 1.Generator's US EPA 1D No pOoumen[No:' ' <br /> WASTE MANIFEST, ' �� os. <br /> -3:GeneratorsiName and-MaAng address - <br /> kJi3,��1�L1 <br /> 4.Generator's Phone( ") 254-i:32'11 } - <br /> _ 5.:Transparter.l'Company Name- &. t. U AID_Number - Atate Transportefs ID <br /> -�•: _'r:- - <br /> 7 Transporter 2 Company Name... _ - _ 8 �-US'EPA ID,Number'� - � C.State Transporters ID <br /> - - <br /> .'D.Transpoiter2 Phone <br /> 4:Designated Facility Name and Site Address-- 1 q'. US EPA TD.Number E.State Fad <br /> .9: <br /> ID - - - - <br /> {3 _jVi 3', F.Faci4itys Phone <br /> 23430 ' <br /> ` 1,12. Containers f iml -_ .. 13. 14. <br /> it <br /> .11:WASTE DESCRIPTION - - Total Unit <br /> No : ._ Type...:,` Quantity - W1Noi.: <br /> aLv70 � <br /> E. I <br /> E, <br /> A <br /> "' -Il..Handlmg Codes for.Wastes Listed Above 'G.Addilional i]escriptions for-Matenals Listed Above <br /> i <br /> �ous :473 LZ' <br /> 15 Special Handlmglns_iructtonsand Additionallnlormation �Q4] C9i4.v r •�:Q�% o+3 •� � , <br /> 71-i J 5 <br /> r: <br /> 6.GENERATOR'S GEN R'5 CERTIFICATION:I,hereby certify that the contents of.lhis shipment are fully and accurately driscnbed and are m akl respects - <br /> :irrpropsrconditionfor transport Tl)e:rnalerials_describad on this manifest.are not subject to federal hazardous waste regulations _ <br /> g Month Day Year, <br /> Pnnted(Typed Na ' r - Si nattne f .- <br /> l., . <br /> Transportek 1-Acknowledgement of Receipt of Materials <br /> R' Signa a th ayy Year <br /> Print Name` <br /> S : Date' - <br /> PQ 1B Transporter2 Acknowle montof Reoept of Matehals' <br /> R' Prinlad]Typed-Name <br /> Signature <br /> T <br /> Month Day Ysat <br /> R <br /> 14.Discrepancy indication Space <br /> A <br /> G, 20 Facitity Owner orOperator;CerLficalion of receipt c <br /> if the waste materials covered by this Mani est except as noted in item 1.9 <br /> L: bate <br /> {• _ - ,Sgna[ure Month';. Day_ Year <br /> -'� t?nntedliypod Name - - - <br /> eV:3795 <br /> -1a2W2 -1J16E.LMAS'f8[0-(e001821.5808 www labelmtLtter,Com pt'msiEaa+rtEcmeoriv'fa reuuo+n - R - . <br /> .. - - soysowlVli INK Y - . <br />