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NON . 1AZARDOUS WASTE MANIF...3T <br /> Please print or type (Form designed for use on elite(12 Pilch}typewriter) <br /> NON-HAZARDOUS I.Generator's US EPA ID No. Maned 2.Page 1 <br /> WASTE MANIFEST :3" Document No. <br /> a of <br /> 3.Generator's Name and Mailing Address I <br /> 7r <br /> 4.Generator's Phone( <br /> 5.Transporter 1 Company Name 6. US EPA 10 Number A.State Transporter's 10 <br /> '2'!: `!:).L 7 1 1 4 F'E'. "AT, �.C!x !, ' B.Transporter I Phone <br /> 7.Transporter 2 Company Name a. US EPA ID Number - C.State Transporter's tD, <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number E.State Facility's ID - <br /> i <br /> "?+'�'r y':r•��r- ^�_1 ti t• ,i F.Facility's Phone i <br /> 11.WASTE DESCRIPTION 12. Containers 13. - 14. ; <br /> Total Unit <br /> No. Type Quantity ! WtNol. <br /> a. <br /> t i <br /> T t.�'f•`t� 1 <br /> � I <br /> N i <br /> E. <br /> R e. <br /> A <br /> T <br /> O • <br /> R d. <br /> I <br /> G.Additional Descriptions for Malerials Listed Above H.Handling Codes for Wastes Listed Above <br /> 1. F1J=7—f:1� is_i°)1_. ,vitt ' i <br /> 1 <br /> 15.Special Handling Instructions and Additiaaal Information ,- ,}k� r'y[; ; 1,'=?Cr M.)`S i`e3C 4. <br /> 1G z <br /> -07 <br /> I <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 matenals described on this manifest are not subject to federal hazardous waste regulations. <br /> 4 <br /> Date <br /> Printecirfylped Name_, Signature _" _ Month Day Year j <br /> 7 17.Transporter 1.Acknowledgement of Receipt of Materials Date i <br /> R <br /> jp Printed/Typed Name Signature / - Month Day Year <br /> 00 16.Transporter 2 Acknowledgement o1 Receipt`of Materials _ Date <br /> TPrintedrryped Name Signature Month Day Year I <br /> E <br /> R 1 <br /> 19.Discrepancy Indication Space j <br /> F II <br /> A l <br /> -I <br /> Ci i <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 Date <br /> T Printedi typed Name Signature Monih Day Year € <br /> Y <br /> I <br />