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NC HAZARDOUS WASTE MAN1rEST <br /> ,Please print or type (Form designed for use on elite{12 pitch)typewriter) - 2.Page t <br /> 1.Generator's US EPA It}No. Manifest <br /> NDN-HAZARDOUS _ _ Document Nor of <br /> WASTE MANII=EST f ' <br /> 3.Generatof's Name and Mailing Address = <br /> 4.Generator's Phone( ', '. ) <br /> 6. US EPA ID Number A.State Transponi s eID <br /> 5.Transporter I Company Name w ' <br /> 8-Transporter 1 Phone -- <br /> 7.Transporter 2 Company`Norrie 8. US EPA 0Numder G,State Transpoder's ID 1 <br /> D.Transporter 2 Phone <br /> 9,Designated Facility Name and Site Address 10, US EPA 11)Number E.State Facility's ID <br /> F.Facility's Phone <br /> Ord <br /> 12. Containers At 3. y' 14. <br /> 11.WASTE DESCRIPTION Total Unit <br /> Na Type <br /> Quantity Wt.Nol. <br /> i <br /> a. <br /> G b. <br /> E <br /> N <br /> E <br /> R <br /> A <br /> T <br /> O <br /> d. <br /> E <br /> G.Adddionat Descriptions for Materials Listed Above H-Handling Codes for Wastes Listed Above - <br /> ! ,.....x•^'11 - _.. ��t , ._ . .. �� <br /> i <br /> 15.Special Handling Instructions and Additional Information <br /> 16.GENERATOR'S CERTIFICATION:I hereby certify that the conlents of this shipment are fully and accurately described and are in all respects <br /> m proper condition lot transport.The materials described on this manilest are not subject to federal hazardous waste regulations. <br /> Date <br /> Month Day Yea <br /> PnniWyped Name Signature <br /> Date <br /> T 17,transporter t Acknowledgement of Receipt of Materials <br /> R Signaturd /3f ' �7+" Month Day Year <br /> A PnggtedlTyyped Name .y / - - j ) <br /> Date <br /> b18.Transporter 2 Ackng4ledgement of Receipt of Materials <br /> R Signature - Month Day year <br /> PrinledfTyped Name <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A I <br /> 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 /> y Year <br /> T PrintecVTyped Name - Signature - Montll Aa ; <br /> Y <br />