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I <br /> NON-HAZARDOUS WASTE MANIFEST <br /> Please print or We IForm designed for use on elite(12 pitch)typewriter) <br /> of <br /> NON-HAZARDOUS 1.Generator's US EPA ID No. r `+ ; ;' ': Manifest 2.Page 1 <br /> WASTE MANIFEST : ! DotatmetrtNu. "} ` �'T/ <br /> 3.G8 #, ?,en 4 hlaq{go Address <br /> 4.Gererator's Phone( r'", ')�'• •`_ <br /> 5.Transporter 1 Company Name 6. US EPA ID Number A.State Transporter's iD <br /> ., l.•,:.i _ .fit. .;. ...... .. � ! <br /> B.Transporter 1 Phone <br /> 7,Transporter 2 Company Name 8. US EPA ID Number C.State Transporters ID <br /> D.Transporter 2 Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number E.State Facility's ID <br /> fit <br /> .'..+ 114fli%'.. F.Facility's Phone <br /> 11.WASTE DESCRIPTION Containers 13. 14. <br /> Total Unit <br /> No. Type Quantity WtNol. <br /> G h <br /> E <br /> N <br /> E <br /> R <br /> A <br /> T <br /> O <br /> R d. <br /> W <br /> NG.Additional Descriptions`or Materials Listed Above H.Handling Codes for Wastes Listed Above <br /> D <br /> O <br /> 15.Special Handling Instructions and Additional Information F. - , <br /> Z <br /> Z 16.GENERATOR'S CERTIFICATION:I hereby certiy that the contents of this shipment are fully and accurately described and are In all respects <br /> n proper condition for transport.The materials described on this manliest are Trot subject to federal hazardous waste regulations. <br /> Date <br /> PnnledlTyped Name Signature Monm Day Yawl <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials Date <br /> NPrntedRyped- me .Hfi ` r Slgnaturer.: - 7, <br /> S <br /> P <br /> Q 18. Transporter 2 Acknowledgement of Receipt of Materials Date <br /> R <br /> T Pnnted/Typed Name Signature Month Day Year <br /> E <br /> R <br /> F 19.Discrepancy indication Space <br /> A <br /> C <br /> L 20.Facility Owner or operator:Certification of receipt of the waste materials coverod by th s manifest,except as noted In item 19. <br /> Data <br /> T Printed/Typed Name Signature .on, y111111111V <br /> CF14 02002 LABELMASTER® (800)621.5808 www.labelmaster.com <br />