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Please print or type <br /> (Form designed for ase on BL[e(12-pitch)typewftr) <br /> NON-HAZARDOUS 1 Generator's US E�PA)D o M fesfesiDD�oc No Page 1 <br /> WASTE MANIFEST <br /> 3 GeneratoHs Na and ailing Address <br /> 4 Generator's Phone <br /> 5 Trans ompany Name � 6 US EPA ID N A Trarksporter's Phone� <br />' 7 Transporter 2 Compan ame 8 US EPA I umber B Transporter's Phone <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Fatuity's Phone <br />' of 11 Waste Shipping Name and Description 12 Containers 13 14 ± <br /> PP 9Total Unit <br /> No Type Quantity Wt(Vol x <br /> Mi a <br /> p�7 <br /> � � - - <br /> G b <br /> E <br /> r" N <br /> E <br /> R <br /> A c f <br /> T <br />' r R <br /> =i R <br /> d <br /> G <br />' D Aciditi I Descriptions for Materials Listed Ab a / �� E Handling Codes for Wastes Listed Above <br /> 1 <br /> 1 <br /> 15 Special Handling instructions and Adddionai Information <br /> �z <br /> 4 <br /> 16 GENERATOR'S CERTIFICATION I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste <br />' J PnntedfTyped Name Signature Month Day Year <br /> T 117 Tran.p'kler 1 Acknowled m t of Receipt of Materials <br /> Print yped Name nature Y r <br /> V P <br /> S \� <br /> O 18 Transporter 2 Acknowledgement of R celpt of Materials <br /> T PnntedfTyped Name Signature V Month Day Year <br /> E <br /> R <br /> 19 Discrepancy Indication Space <br />' F <br /> A <br /> C <br /> 20 Facility Owner or Operator-Certification of receipt of waste materials covered by this manifest except as noted in 19 <br />' Y yped Name Y, <br /> ` <br /> ` 41� 61- <br /> ✓ti <br />' Printed by J J KELLER 8 ASSOCIATES INC 12-BLS-05 Rev 12198 <br /> Neenah W1 54957-0368 ORIGINAL-- RETURN TO GENERATOR <br />