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DOUS WASTE MANIF,,;T <br /> NON-HAZARDOUS � <br /> Please print or type (Form designed for use on elite(12 pitch)typewriter) 2.Page I <br /> 1.Generator's US EPA 1D No. Document <br /> Manifest <br /> NONHAZARDOUS °°come°'"°. of <br /> WASTE MANIFEST <br /> 3-Generators Name and Mailing Address <br /> 4.Generators Phone( ^� } -: ••-`?^: ! <br /> S.Transporter t Company Name 6- CJS EPA 10 Number A.State Transporter's 10 <br /> B.Transporter I Phone <br /> i i <br /> - 7.Transporter 2 Company Name 8. US EPA 10 Number G.State Transporter's ID <br /> r <br /> D.Transporter 2 Phone l <br /> 9.Designated Facility Name and Site Address t0. US EPA ID Number E.State Facility's ID <br /> F.Facility's Phone <br /> 14. <br /> 11,WASTE DESCRIPTION12. Containers+ Total Unit <br /> No. Type Quantity Wt.Nol. <br /> a. j Jj /ry y l <br /> G b. <br /> E <br /> N <br /> E <br /> R <br /> C.A <br /> T <br /> 0 <br /> R d. <br /> m <br /> H.Handling Codes for Wastes Listed Above <br /> G.Additional Descriptions for Materials Listed Above <br /> I <br /> s <br /> .Ta <br /> ' 15.Special handling Instructions and Additional information -• 33 <br /> Ll <br /> .mob 16.GENERATOR'S CERTIFICATION;I hereby certify that the contents of this shipment are fully and accurately described and,are in all respects I <br /> in proper condition for transport.The matenals described on this manifest are not subject to federal hazardous waste regula,ions. i <br /> I <br /> f` Date <br /> Print yPed Name F Signatures 7r ^ ,//• , ` ,ti Month Day Year <br /> r ; 4 <br /> �r,. F Date � <br /> T 171.Transporter I Acknowledgement of Receipt of Materials 1 <br /> RSi gnature ; f Month Day Year <br /> Pri <br /> N djT �d .am f rfi <br /> pa I <br /> S / - <br /> P Dais <br /> 18.Transporter 2 Acknowledgement of Receipt of Materials , <br /> R Printed/Typed Name Signature Month Day Year <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A ' <br /> C <br /> 20.Factlity Owner or Operator;Certification of receipt of the waste materials covered by this manifest,except as noted in item 19. <br /> L Date <br /> T Pnnted(Typed Name - Signatusa <br /> Monlh Day Year <br /> Y <br />