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NON-HAZARDOUS 1 Generators EPA ID No Mandesl Doc No 2 Page t <br /> WASTE MANIFEST of <br /> 3 Generators Name andILng Address <br /> L' Oa/// �� <br /> 4 Generators PhoneZO/ <br /> 5 Transporter 1 Company Name 6 ,(L7PA ID Number A Transporter's``Phone <br /> !:2-7'�Z <br /> 7 Transporter 2 Company Name 8 S EPA ID Number B Transporters Phone <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility s Phone <br /> /J2 <br /> I <br /> 13 14 <br /> 11 Waste Shipping Name and Description 12 Containers Total Unit ' <br /> 1 No Type Quantity WVVOI <br /> a rr <br /> O i <br /> �w <br /> G b <br /> E <br /> N <br /> E k, <br /> R <br /> s <br /> c A c <br /> T <br /> 0 <br /> R <br /> r� <br /> d e <br /> t <br />!' O Aeoiuonai Descnp,iors for Mate ials Listed Above E Handling Codes for Was es Listed Above a <br />`' 7/94K t <br /> 15 Suecial Handling Insirucoons and AOddional Inforra'on <br /> F <br /> r �/1�.�✓S _ ��/i�QL f �v ��L� fes(//l��/��-f�G/r!���c �.�.�c�.� <br /> f <br /> I <br /> i <br /> i 16 CENERATOR S CERTIFICATION i ce'U y t e e ,tis des nbec aoo�e C^ s rarilest a e nc s.rtrlaci iD feoe al rcoulaticns for rercr,ng p oper c t*osai of Naza daJs 1'ac e ' <br /> f <br /> Frin,edlTvped Name q^ i ie rfor1, Gay rear <br /> r r`'��- �} �-t_ t Ai-A I b3 <br /> AT 7 Transponer 1 Ac0c"Icdoeme-i of Receipt 0110.er als <br /> 1 A pr,lec[/Tlpcd Name = I Signa ui 1 Ir�^' IIC, YEer <br /> 0 18 Trarsponer 2 ACknoA1edQemer1 of Receipt of Ma eras <br /> R <br /> T Pnnlcd,7�ped Name Signature r9or ti pay Yea <br /> R , <br /> 19 Discrepancy indication Space <br /> F <br /> A <br /> C <br /> I <br /> L 20 Facolny O,�ner or Operator Certi'ication of receipt 01 r+axle materials cove ed by his man,test except as noted in Item i9 <br /> I <br /> PrintedfTvped Name Signature Mar n p.-y 1 ear <br /> Bil-1- 74C <br /> PnniedbyJ J KELLERdASSOCIATES INC 12-BLS-05 Rev 1219$ <br /> Neenah 4'JI54957-0368 <br /> ORIGINAL — RETURN TO GENERATOR <br />