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%mi <br /> NL HAZARDOUS WASTE MANivEST <br /> Please print or type (Farm designed for use on elite(12 pitch)typewriter} _ 2 Page 1 <br /> 1.Generator's US EPA ID No. Manifest <br /> NON-HAZARDOUS m gocumeniNo _ of <br /> WASTE MANIFEST c <br /> i <br /> 3.Generator's Name and Mailing Address <br /> 77, <br /> 4.Generators Phone <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A,State Trarsporter's ID _ - <br /> 1rs ? S B.TransQortnr1 Phone 7,1' +_ <br /> 7.Transporter 2 Company Name 8. US EPA ID Number G.Slate Transporters I <br /> D-Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number E.State Facility's ID <br /> e_ <br /> F.Facility's Phone <br /> uG <br /> 12. Containers 13. 1 t <br /> 11,WASTE DESCRIPTION Total Unit <br /> No. Type Quantity Wt.Noi, <br /> a (y <br /> V 71 <br /> G t <br /> E <br /> N <br /> E <br /> R c. <br /> A <br /> T <br /> O <br /> i" H,Handling Codes for Wastes Listed Above II <br /> '-�,- G.Additional Descriptions for Materials Listed Above <br /> i <br /> .46 <br /> i <br /> ! <br /> - 15.Special Handling Instructions and Additional Information <br /> .T J1r':ae 7 'J•.7.:i�a�... ..,.•.-.-.?;�".7-`: �t-�`,� ... ' <br /> If <br /> 16.GENERATOR'S CERTIFICATION:i hereby certify that the contents of this shipment are fully and accurately descnbed and are rn all respects ! <br /> .e in proper condition for transport.The materials described an This manifest are not subiect to federal hazardous waste regulations. <br /> I <br /> i <br /> Date <br /> I <br /> a Si nature 'l Month Day Year <br /> grin yped Name Y <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> A Pr t yped Name Sigga�t Month Day Year <br /> ig /, <br /> IN <br /> PIS.Transporter 2 Ackn ledgement of Receipt of Materials Date <br /> R Signature Month Day Year <br /> T Printetl+fyped Name <br /> E <br /> 19.Discrepancy Indication Space <br /> i <br /> F <br /> C f <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 /> L - Date <br /> II <br /> T' Printed/Typed Name Signature Month Day Year <br /> Y <br />