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Please rim or type <br /> (Form designed for uae on aIRe(12 proch)typewriter) <br /> NON-HAZARDOUS 1 Generates US EPA ID No Manifest Doc No 2 Pagel <br /> WASTE MANIFEST <br /> 3 Genertors Name and Mailing Address 64 Z�� <br /> IMAX" <br /> I 41- 12, f <---4i <br /> 4 Generator's Phone(_,<C)r)✓_L _-7 <br /> Sµ-Trar�a7ftorf�r 1Company Nie_ B US EPA ID Number A Tporter's Phone <br /> 02- 1 <br /> 7 Transporter 2 Company Name 8 US EPA If)Number 6 Transporter's Phone <br /> 9 De�ig ted Facility Narpe and Site Address 10 US EPA ID Number C Facilsty s Phone <br /> 11 Waste Shipping Name and Description i2 Containers 13 14 <br /> Total Unit <br /> No Type Quantity WWoI <br /> � V ' { t s � r` <br /> c A Zas�-C_ <br /> G b <br /> E <br />' N <br /> E 3 <br /> R <br /> A c <br /> T <br /> o <br />' R <br /> d <br /> D dditional Descriptions for Materials Listed Above E Handling Codes for Wastes Listed Above <br /> 15 Speciai Handling instructions and Additional Information <br /> F <br /> 16 GENERATOR'$CERTIFICATION I certify the materials described above on this manifest are not subject to federal regula ons for reporting proper disposal of Hazardous Waste <br />' Pnnted/Typed Name Signature Month nay Year <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> '- R <br /> SPrtntedlT / ame Signature_ gym! >' Month Day/ Year <br /> P <br /> R 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> T Pnnted/fyped Name Signature Month Day Year <br />' E <br /> R <br /> 19 Discrepancy Indication Space <br /> F <br />' A <br /> C <br /> I <br /> 20 Facility Owner or Operator Certification of receipt of waste materials covered by this manifest except as noted m Item 19 <br />' peed Name ignature 'nth Day Year <br /> ` ✓ r f �.. 67 <br />' Printed by J J KELLER&ASSOCIATEs INC 12-BLS-05 Rev 12/98 <br /> Neenah WI 54957 0368 <br /> ORIGINAL-- RETURN TO GENERATOR <br />