Laserfiche WebLink
NC HAZARDOUS WASTE MAN. _--ST <br /> Please print or type {Form designed for use on elite(12 pitch)typewriter} I <br /> NON-HAZARDOUS 1.Generalor's US EPA ID No. Manifest 2.Page 1 <br /> Document No. <br /> WASTE MANIFEST "' IV?2 :T! ')-)I ;-�� of <br /> 3.Generator's{Jame and Mailing Address I <br /> .t !�'I y �-sir '�+� 'i3i��r •.�f.�.f"--A.!.r f CIA <br /> 4.Generatoes Phone ?- <br /> 5.Transporter Y Company Name 6. US EPA ID Number A.State Transporters ID <br /> B.Transporter 1 Phone ` ,. <br /> 7.Transporter 2 Cqmpany Name 8. US EPA ID Number C.State Transporters ID ' <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 16. US EPA 1D Number E.Stale Facility's ID <br /> #.M ',�,; [°�+-^i'a £'-�.'-�?+` F.Facility's Phone <br /> —2317 <br /> 11.WASTE DESCRIPTION 12. Containers 13. " 14. <br /> Total _ C Unil 1 <br /> No. Type Quantity '. Wt.lVol. <br /> a. <br /> E <br /> N � <br /> E � <br /> A 1 <br /> R d <br /> G.Additional Descriptions for <br /> Materials Usled Above - - r - H.Handling Codes for Wastes Listed Above <br /> I <br /> E <br /> 15.Special Handling Instructions and Additional Information <br /> 71. <br /> 71 <br /> 16.GENERATOR'S CERTIFICATION:I hereby certify that the contents of this shipment are fullyy and accurately described and are in all respects <br /> in proper condition for transport.The materials described on this manifest are not subject to lederal hazardous waste regulations. <br /> Date j <br /> Priniedrryped Name _ Signature - Month Day Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R <br /> A Printed/TypedName Signature - Mo,fh Day Year <br /> p18.Transporter 2 Acknowledgement of Receipt of Materials Date <br /> TPrintedrryped Name Signature - - Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 24.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 PrinteciTyped Name - Signature - Month Day Year <br /> Y <br /> ..�,,...... ...r.1�A..-.....�•e..n:c.,.rene .._....:�.moi..��.�.���. /*\ A <br />