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Osi <br /> deaian«e+l` S � ` } <br /> ���3BI1te�azlYPewrtlerd,. :..��- �.� <br /> NON-HAZARDOUS 1 Generators US EP ID No Manrlesi Doc o 2 Pagel <br /> WASTE MANIFEST of <br /> 3 GerlQrator Name and Marling Address <br /> .NCI <br /> 1'> , <br /> 4 Generator s Plfone -7- <br /> � <br /> Y <br /> 5 Transporter 1 Company Name 6 U5 EP k Number A Transporters Phone <br /> /f <br /> 7 Transporter 2 Company Name 8 US EPJ ib Number B Transporters Phone <br /> 9 „Pgsignated Facility Name and Site Address 10 US EPA ID Number C Facility s Phone <br /> LJ) P- q3 9�-I <br /> r <br /> 11 VJasle Shipping Name and Description Containers 13 14ptlon Total Unit ?� <br /> No Type Quantity WtN01 <br /> J <br /> r� G b 3: <br /> E r <br /> I- E <br /> 7 c <br /> Q <br /> J4_ <br /> D Add conal Descr pt,ons for Malcrrals LISled Above E Handling Codes for V%asses Listed Above <br /> 15 Spec al Handling Jns,rLCLQ-)S and Additional Wo ma ion <br />�a y <br /> r <br /> &U <br /> �6 GENERATOR S CERTIFICATION t cc,,fv the rra cr c s c—c L cc a>;ete cn r e`,'e<.are not sublec,to cdc el regu a ices for epering proper C spcsal of Haz,rdOLS%`aS e <br /> ped Name �I 1.1"n h Dar, tea <br /> c� i <br /> R ' i .. sporcr 1 %,Crtnoxledl- 61 peceipt of Ma'e is 5 <br /> AI Pnr, llc//Typec.N'a-e � ;Igralu la0^y 0- 1 tear <br /> RTromspor'er 2 Ackna+ ledger-ert o`R celpt c'11a,enals <br /> EPrintoo/T)+pec Name S gnatire von h Day 1 ear <br /> R <br /> 19 DscrepancyIndication Space <br /> F <br /> A <br /> C <br /> I <br /> U 2p Facd'y O"ner or Operator Certlf Caton o1 receipt of waste materials co a ed by this manifest except as noted in Item 19 <br /> nfed-T%ped Name SIgnalure Month Day rear <br /> Ag <br /> pnnted by J KELLER&ASSOCIATES INC 12-BLS-05 Rev 12/98 <br /> Neenah WI 5495]0368 <br /> ORIGINAL. — RETURN TO GENERATOR <br />