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1 <br /> (Fortn designed for use cn elite(12 pitch)typewriter) <br /> NON-HAZARDOUS 1 Generators US EP ID ' Mandest Doc No 2 Page i <br /> f WASTE MANIFEST /� ��/� /o1 <br /> 1 - <br /> 3 Gen/eraivr s and Mailing Address <br /> /G_,./� <br /> t 4 Generators Phone(� <br /> 5 Transporter 1 Company Name fi US EPA ID Number A Transporters Phone <br /> 7 Transporler 2 Company Name 8 US EPA ID Nu(nber B Transporter s Phone <br /> 9 Designated Faciiity Name and Site Adoress 10 US EPA ID Number C Facility s Phone <br /> 11 Waste Shrpping Name and Description 12 ContainersFouanlity <br /> 13 1a <br /> Total Unit <br /> No Tvpe wh"Vol <br /> a <br /> G b <br /> E <br /> N <br /> E <br /> R <br /> A c <br /> T <br /> O <br /> R <br /> r <br /> d <br /> D Aad rcrip ions'or t'a'e ials Lis ed Above E Handling Codes for Wasies L sled Abov e <br /> 15 Special H2noling lrstruclicns and r.ddi,or al In'ormd'�cn <br /> I <br /> 16 GENERATOR S CERTIFICATION ce- y t— s C�sc cea a`uc,e;r s an'ecr o e-1,1 o ec 'o cee c'regula ionS for rcaen re.^r-,De.r= ,.f e tic« nc-s tics c <br /> Printe❑i7yped Name 5igr�, re , Day }car <br /> T I .7 Trarsportar 1 ACKroi ledce-nent o1 Receipt of Rid G a's <br /> A _)Dr .eC Ttip d N.7's ` _ Si�g,a1jre� 1 - Sir D Ytsr <br /> P <br /> O 18 Transpor'er 2 Ackno%NfedgE ent of Receipt o.kr,alena.S <br /> R <br /> E Pr nteC,7)ped Name ` Sigr2'u e ✓an r Day 1 ear <br /> R <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> f <br /> E 20 Fac Illy Oti%ner or Operalor Cenfication of receipt of t,as.e materials co e ed by.his mamiest except as neled in Item 19 <br /> P Nae[/� ' � r ' f „r Day 1e�r <br /> Pnnieo by J J KELLER 8 ASSOCIATES INC 12-BLS-G5 Rev 2/98 <br /> Neenah WI 54957 0368 <br /> TRANSPORTER41 <br />