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11 8 w9jil, ti <br /> NOM-HAZARDOUS 1 Generators US EPA ID No Man:test Doc No 2 Page 1 of <br /> WASTE MANIFEST ' <br /> 3 Generator s Name and Mailing Address <br /> 4 Generators Phone( _z- <br /> 5 <br /> r-5 Transporter 1 Company Name 6 US EPA ID Number A Transporter's Phone <br /> 7 Transporter 2 Company Name a US EPA ID Number B Transporters Phone <br /> 9 Designated FaCillty Name and Site Address 10 US EPA ID Number C Facslitys Phone <br /> 11 Waste Shipping Name and Description Containers 13 14on Total Unit <br /> No Type Quan,oty WWoI <br /> a <br /> G b 7 <br /> E <br /> N <br /> E <br /> R <br /> F' A c <br /> Fx T <br /> s O <br /> r; <br /> R <br /> d <br /> 3� <br /> h <br /> t <br /> D Additional Cescrtplions for Materials Listed Above E Handling Codes for Wastes Lrsted Above <br /> r <br /> t 15 Special handling InsirucLons and Additional Information <br /> :o <br /> ti <br /> -6 GENERATOR S CERTIFICATION I verity the 7.'enals GescnbeC above on Chic mam est are not subject to fcce at regulations for reponrnc,proper ampesal of Ha2ardcjs Waste y y <br /> Pnnfedrfvped Name Signature Month pay Year <br /> `', <br /> T 17 Transporter 1 Acknowledgement of Receipt of M'arer als <br /> R vrnl17 D )ear }1 <br /> A PrrrtedlTvped Name Signaturd `/(1 �y 11 <br /> A <br /> S � V <br /> P <br />' O 18 Transporter 2 Acknowledgement of Rececpt of Ma erlais 7f <br /> R ti= <br /> T Prinled/Typed Name Signatu e f"onth Day rear r <br /> E _ ice <br /> e R <br /> 19 Discrepancy Indication Space L <br /> F .+ <br /> A ,v <br /> C <br /> I <br /> y <br /> 20 Facility O,ner or Operator Geni'ical on ct receipt o'Haste mate ial5 covered by this mandesl except as noted in Item 19 , <br /> .s <br /> PrsntedT}ped Name Signature Monrh Dav +ear <br /> , <br /> i •' <br /> Panted�lryJ 3 KELLER s ASSOCIATES,ING`Y ? 12-BLS-05 Rev 12198 ' <br /> Neenah WI54857.a68 ��1 - ` - + = , <br /> GENERATOR S COPY t '_�� �� __ y..__. <br />