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Y <br /> x*P(FIoBara!� elouec1:111t2111)) fi <br /> ap " r <br /> NON-HAZARDOUS 1 Generators US AID No Manifest Doc No 2 Page 1 <br /> WASTE MANIFEST of <br /> 3 Generators Nam d Ma1iing Address <br /> A Gene ) _ i1/1/ <br /> 5 Transporter 1 Company Name CJIO 6 US EPA ID Number A Transporters Phone <br /> 7 Transporter 2 Company Name S US EPA ID Number 6 Transporter s Phone <br /> S Designated Facility Name and Site Address 10 US EPA If]Number C Facility s Phone <br /> '_Ad—jt—�7_ <br /> 11 Waste Shipping Name and Description 12 Co-itairters 13 14Total Unit =a <br /> He Tvpe Quantity WtrVol <br /> 5'F <br /> r G b <br /> F7 E 5 h <br /> Ck N <br /> ' E zyx <br /> 1„ R 'Y <br /> A c <br /> r T fg <br /> 0 <br />� s <br /> f' d <br /> r" <br /> t <br /> I I D Aadi,oral DeEcrip,ions for 1 ra mals Lis-ee Above E Handling Codes for Wastes Luted Abo%e v <br /> f <br /> f - <br /> r r5 Special Hanaling Instruc,ions and Addy,enal Irf rma,^n 4 <br /> r <br /> E�� �c��J�„'C/ - ^ _C� /�'G L�✓/LLQ �' CZ3 <br /> I <br /> 16 GENERATOR 5 CERTIFICATION I rc-r'v rc me --s test Ice aoove on r s men es are nct e ect a fecc I rogula ions for*cp�r-rrg;rower spo=ol or Hozarooug Was e <br /> Prinlea'TLped Name I ^ Lay lea <br /> TRQq CAJ IL-Lt 41-4 (zu,�Ao <br /> T 17 Transpo-er 1 ACKnOti leoae-ne-t of Receipt of fJa iE F'S <br /> R <br /> A PrIn4E0 r m2 �� S13na ! Cn CPv YE2r <br /> R 18 Transporter 2 Acknan leogeme^4 of Receipt of Maier als - <br /> T Ann eo Typed Name Sigr-a'ure I on n Day Year <br /> R <br /> 19 Discrepancv Indica,on Space <br /> F <br /> A <br /> C <br /> 1 <br /> L 20 Facdi v 0% ner or Operator Cer,if talion of receipt Of ua-le rriatena's cove ed by this manifest except as no ed jr,Item 19 <br /> Print red Name �y� Src - rjonra Dey Year <br /> Pnnled by J J KELLER 8 ASSOCIATES INC <br /> Neenah WI 64967 12-BLS-05 Rev 2/98 <br /> -0';6s <br /> ORIGINAL — RETURN TO GENERATOR <br />