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NON-HAZARDOUS WASTE MANIF`ff <br /> Please print or type (Farm designed for use on elite(12 pitch}typewriter) <br /> NON-HAZARDOUS 1.Generator's US EPA ID No. Manifest 2 Page 1 <br /> Document No. <br /> WASTE MANIFEST of , <br /> 3,Generator's Name and Mailing Address <br /> 4.Generator's Phone( i ) <br /> 5,Transporter 1 Company Name 6. US EPA 10 Number i A.State Transponei s!D <br /> B.Transporter 1 Phone <br /> 7_Transporter 2 Company Name 6, US EPA ID Number C-State Transporter's ID , <br /> I <br /> D,Transporter 2 Phone <br /> 9,Designated Facility Name and Site Address 10- US EPA It]Number E.State Paciliry's 10 <br /> F.Facility's Phone <br /> 11.WASTE DESCRIPTION➢ 12. Containers J 13. 14. <br /> _ Total Unit <br /> _- No. Type Quantity wt.Nol• <br /> x <br /> a <br /> G b. <br /> f <br /> N <br /> E <br /> R <br /> A <br /> T <br /> O <br /> fi d. <br /> G.Additional Descriptions for Materials Listed Above H.Handiing Codes for Wastes Listed Above <br /> ._ ... -. .. i <br /> i <br /> 15.Special Handling Instructions and Additional Information i <br /> 1 7 f <br /> 16.GENERATOR'S CERTIFICATION:!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 materials described on this manifest are not subject to lederal hazardous waste regulations. <br /> Date <br /> -<' Signature Month Day Year <br /> PrintedlTyped Name _ 9 - p <br /> T 17.•Transponer 1 Acknowledgement of Receipt of Materials - Date <br /> A PrinledlTyped Name -� Signature f'�F f; f`:• Month Day Year <br /> 41 <br /> p1 a.Transporler 2 Acknowledgement of Receipt of Materials r Dale <br /> T Printed/Typed Name Signature Monfh Day Year <br /> T <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> 20.Facility Owner or Operator;Certification of receipt of the waste materia?s covered by this manifest,except as noted in item 19. j <br /> L Date <br /> T PrintedrTyped Name Signature Month Day Year 1 <br /> i <br /> Y i <br />