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Please pnM ortype <br /> (Farm designed for use on elite(12-pftafi)typewriter) <br />' <br /> JT <br /> NON-HAZARDOUS 1 Generators US EPA ID N9 Manifest Doc No 2 Pagel <br /> TE MANIFEST N/a 10001 1ef 1 <br /> 3 Generators Name and Mailing Address <br /> cheveron <br />' ;- Z o d i r ca hivy 12 <br /> 4 Generator's Phone{ ) <br /> 467-1006 <br /> 5 Transporter 1 Company Name S US EPA ID Number A Transporter's Phone <br /> thrifty rooter n/a 673-8201 k` <br /> 7 Transporter 2 Company Name 8 US EPA ID Number B Transporter's Phone ` <br /> u4 k ha <br />' 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility s Phone Mkta <br /> inviro tec <br /> 2480 athens ave n/a 434-0211f, <br /> c 11 Waste Shipping Name and Description12 Containers T63tal Unit <br /> No I Type ouantity WWol ; <br /> I* <br /> #A <br /> a non haz waste liquid � <br />' waste water 001 tt �LA 6 <br /> t G b <br />' r E v= <br /> ' E <br /> u^ R <br /> c A c $ <br /> T 0�= <br /> = o <br /> a3� d <br /> tR <br />' 4 D Additional Descriptions for Materials Listed Above E Handling Codes for Wastes Listed Above <br /> purge water fom tank <br /> Sm 15 Special Handling Instructions and Additional Information <br /> emerg contact; ; abco troy w. 916-826--3803 <br /> I 4z <br /> " ( s <br /> F <br /> I F <br /> 5a 1 <br /> 16 GENERATOR'S CERTIFICATION I certq the materials described above on this manifest are not subject to federal regulations for reporpng proper disposal of Hazardous Waste �+ <br /> ,F Printed/Typed Name Signature Month Day Year <br /> N to <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials w <br />'V0 A edrr e e n 4 Month Day Year ✓Ir <br /> - <br /> 5r <br /> P <br /> R 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> E PnntedfTyped Name Signature Month Day Year <br /> F R <br /> 19 Discrepancy Indication Space <br /> ,r F <br /> A <br /> G <br /> 20 Facility Owner or Operator Certification of receipt of waste matenals covered by this manlfe�t�xcept as noted inlern <br /> Y Pnnted/Typed Name Signaturepwe aye Year <br /> BILL ARTAMENK0 <br />' Printed by J J KELLER A ASSOCIATES INC 12-BLS-05 Rev 12/9$ <br /> Neenah WI 549570368 ORIGINAL- RETURN TO GENERATOR <br />