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Phu= pr� % <br /> �q-Wl12p trh� awrlter <br /> - ♦ �i� .;�s j1yRH�sy � <br /> NON-HAZARDOUS 1 Generators U PA ID No Mantles DOC No 2 Pagel <br /> r <br /> WASTE MANIFEST ( Q of <br /> 3 Generators Name and M fling Address <br /> c'fl��`Qo - <br /> �oo <br /> 4 Generator s Phone( > --1� <br /> 5 Transporter 1 Company Name 6 USE ID Number A Transp er s hone <br /> 7 Transporter 2 Company Name g US PA 1D Number 8 Transpor3ers Phone dip <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility s Phone <br /> CNV 12( TGZ__ <br /> 13 14 <br /> V- <br /> 11 waste Shipping/Name and Description 12 Containers Total Unit <br /> In <br /> No Type Quantity UJtlVol <br /> � a /tli( �i lam!4 U/� �J✓�S� _ <br /> i <br /> E b r <br /> N F� <br /> E <br /> _ R <br /> A c t <br /> v p <br /> R <br /> ;w <br /> t <br /> ` D Addition�I Desc iptior�for li+a er Gis Lisled Aoeve Handling Codes for Wastes Lis ed Above <br /> f <br /> F <br /> t <br /> I 15 Special t anoling InstrLCtlons and Additional lnrorr-a'cn <br /> t <br /> Tle <br /> 16 GENERATOR S CERTIFICATION I,er'y tie <e is de<c ILe7 soove or hl< z^d0<t a c no E.becl io ICcc I eoLIt11C/s'or cponina piopr_r disporai of Haze JC-S e <br /> Pr+rledr T ti ped Name e <br /> I , <br /> RTE 17 T,enspo'rr 3 MGknoti+leo_ce a^t of REcCIp,of k1a e iais " <br /> N v <br /> Pee aii 5ignat car yt <br /> O 18 Tra�spor€r 2 Acrnc% leogemert of R,ecelp,o1 Va€reals <br /> E Pnn,ec17+red Name S gna,ure rsor Day car <br /> R <br /> 19 Discrepcncv Indica ion Space <br /> F <br /> A <br /> C <br /> I <br /> 20 Facddy 0%+ner cr Operator Cenihcation of receipt o' aSle mala',aiS Co+e CO by 1h s maridest except as noled in dem 19 <br /> 7'r'ed Marne ignaiur � 111pr n Dav - <br /> Printed by J J KELLER 8 ASSOCIATES 4NC <br /> Neenah Wt 5495]-01&8 12-BLS-05 Rev 12J98 <br /> ORIGINAL — RETURN TO GENERATOR <br />