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11 <br /> e (Earn db�gnad taAne ate <br /> NON-HAZARDOUS 1 Generator s US PAID No Manifest Doc No 2 Pagel <br /> WASTE MANIFEST /v of <br /> 3 Generators Name and Mailing Address <br /> 4 Generators Phone{ 7— � <br /> 5 Transporter 1 Company Name 6 US EP ID Number A TransporSers Phone <br /> U rLc� --. G - <br /> 7 Transporter 2 Company Name 8 US ltPX ID Number B Transporter s Phone <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility s Phone <br /> IBJZ " <br /> 14 <br /> 11 Waste Shipping Name and Description 12 Containers Total Unit <br /> No Type Quantity WUVol <br /> Tr <br /> k <br /> J ±� <br /> G b a <br /> E <br /> N <br /> E <br /> A c c <br /> T r <br /> O <br /> R <br /> d 4 <br /> F_ <br /> 1 - <br /> i =SR <br /> D Additional Descnptiens'or IJaterials Listed Abo\e E Handling Codes for V�astes Listed Above <br /> t 15 Special H.ndling Ins ructions cnd Additional Info rnG,i;m <br /> tt/ PPC1 1,c1'h�n hug / <br /> I <br /> 16 GEtJERATOR S CERTIFICATION I ccrif�t7e ei L s tl[sciibed t^c�e en -rra-Iasi z e nes�ur,ett c'ece al rrou aiiors fo reposing,Doer c tpesai os Hazarda..s <br /> j' I Signat r-�� l4onlh Cry 1 ear <br /> Pair i;c7}pec Name � C i <br /> r <br /> T 17 – nSporE i .'ckrc� lei -mcni of Paceipt o'Mai- r S <br /> R ' �~ 1' C;sat <br /> A i Pri ec T ped<�ame ., <br /> v P <br /> O 18 Trarspo,er 2 Actinoo'cdee-nent of 5eceipl of Nha er EIS <br /> t R - <br /> r T Printeo'Typed Naze S gnatu e !^ter h Dav 1e.,r <br /> E <br /> R <br /> 19 Discfepancy Inaication Space <br /> F <br /> A <br /> C <br /> I <br /> kFaci�ily ONner or Operalor Cenihca,ion of rete pi haste materials co+e ec by this-nandect except as noted in Item 19 <br /> 120 <br /> , � � Mon h Cay Year <br /> dT�ped 1\an�e Signatvrn <br /> Printed by J J KEL.LER 6 ASSOCIATES INC <br /> Neenah WI 54957 0308 12-BLS-05 Rev 12/98 <br /> ORIGINAL - RETURN TO GENERATOR <br />