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Please pprint ar type <br /> (Form designed for use on eine(12-pitch)typewriter) <br /> NON-HAZARDOUS 1 Generator's U EPA ID No Manifest Doc No 2 Page i <br /> WASTE MANIFEST - ---------- y^`, u �' '2 � �of f <br /> 3 Geneplofs Narrte and Maili Addr ss , d— <br /> 4 Generators Phone <br /> 6 Trarysporter 1 Compa2yName 6 US EPA ID Number A Trans orter's Phone <br /> 7 Transporter 2 Company Name 8 US EPA ID Number B Transporters Phone <br /> I9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility s Phone <br /> 11 Waste Shipping Name and Description <br /> 12 Containers 13 14 <br /> Total i r t No Type Quantity Unit <br /> c E b <br /> N <br /> E <br /> - R <br /> A c <br /> _ T <br /> I R d <br /> i <br /> I <br /> dddional Descriptions for Materials Listed Abo`ye�, E Handling Codes for Wastes Listed Above <br /> 15 Special Handling Instructions and Additional Information <br /> I <br /> I <br /> 16 GENERATOR'S CERTIFICATION `[ce fy the matenals descnbed above on this manifest are not subjea to federal regulations for reporting proper disposal of Hazardous Waste <br /> PnntedrTyped Name Signature Month Day Year <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> I S Pn y e 1C j � C ti J Sign ✓ nTan D� Yea.�r , <br /> P <br /> R 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> EPnnted/Typed Name Signature Month pay Year <br /> R <br /> 19 Discrepancy Indication Space <br /> F <br /> I A <br /> C <br /> I <br /> 20 Facility Owner or Operator Certification of receipt of waste materials covered by this manifest a as noted in Item 19 <br /> IY P ed Name natur nm Day Year <br /> I <br /> Pnnted byJ J KELLER&ASSOCIATES ING 12-BLS-05 Rev 12/98 <br /> Neenah WI 54957-0368 <br /> ORIGINAL— RETURN TO GENERATOR <br />