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i <br /> Please print or <br /> (Form designed for use on elite(12-pitch)typewriter) <br /> NON-HAZARDOUS 1 Generators US EPA ID No Manifest Doc No 2 Pagel <br /> ' WASTE MANIFEST n/a Oppl 1 °f 1 <br /> 3 Generator's Name and Mailing Address <br /> cheveron <br /> hwy 12 lode , ca <br /> �r 4 Generators Phone( 209) 467-1006 att ; ; tim ' <br /> 5 Transporter t Company Name 6 US EPA ID Number A Transporter's Phone <br /> thrifty rooter n/a 673-1923 <br /> 7 Transporter 2 Company Name a US EPA 10 Number 5 Transporters Phone <br /> tai � <br /> r"= <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility's Phone <br /> i nvi ro tec tYa, <br /> 2480 athens avec <br /> d — <br /> 11 Waste Shipping Name and Description 12 Containers T3 14 <br /> otal Unit <br /> No I Type Quantity WI/Vol a N <br /> non haz waste liquid nos -C <br /> waste water Dal t <br /> a G b <br /> 1'4CE tF <br /> ' N <br /> R t� <br /> Ac i'1 <br /> t <br /> 1 ' T <br /> I R 1 <br /> w � <br /> I yx 1 <br /> D Additional Descriptions for Materials Listed Above E Handling Codes for Wastes Listed Above <br /> 15 Special Handling Instructions and Additional Information <br /> i <br /> 16 GENERATOR fi CERTIFICATION 1 ceriiiy the materials described shove on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste � vi <br /> s PnntedrTyped Name Signature Month Day Year <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials ~ <br /> y R C <br /> A Q ame J Signatur Mo Day. Year <br /> NCI= S <br /> of <br /> O 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> E Printed/Typed Name Signature Month Day <br /> Year <br /> R ell <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> IC <br /> 20 Facility Owner or Operator Certification of receipt of waste materials covered by this manifest except as noted in Item 19 <br /> Y Pnnte <br /> ped NManth Year <br /> 6? <br /> I Printed by J J KELLER&ASSOCIATES INC <br /> Neenah WI 54957-0368 12-BLS-05 Rev 12.198 <br /> ORIGINAL RETURN TO GENERATOR <br />