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�y����yyhYr T <br /> t Fortin A b K ST"3 W,I- <br /> Formre�t>�w a 17,p Typewrttera'�, tiY �".r.�--- �,'.�r .� -t <br /> NON-HAZARDOUS 1 Generators U5 EPA ID No Manifest Doc No 2 Pagel <br /> sw <br /> WASTE MANIFEST /tJ QQ of <br /> 3 Generators Name and Mglllnp Address <br /> 4 Generators Phone(,2Q�) <br /> 5Transporler 1 Company Name 6 Us EP lD Number A Trans orter Ph e r <br /> �L lV 1/!r2 v /C C)Z <br /> 7 Transporter 2 Company Name S US&A ID Number B Transporters Phone <br /> `r$ <br /> 9 Designated Faculty Name and Srte Address 10 US EPA 1D Number C Facility s Phone � <br /> _TN✓(R8 T ` <br /> w� <br /> #� 11 Waste Shipping Name and Oescnpfion 12 Containers 13 14 <br /> Total Unit <br /> No I Type Quantity V Vvol ` <br /> LU11-5/Ef1__/CSL 1D �✓ <br /> G b <br /> F <br /> z E <br /> fi M <br /> E <br /> R iaK <br /> A ca <br /> T <br /> s^ O h <br /> R _ <br /> k d <br /> k <br /> C - <br /> t y <br /> L D Adoil oral Gescr peons for Materials L�s,ed Above E Handllr,g Godes for V%3s'es L sled.bove <br /> 7 Nlii IK- <br /> L _ <br /> �5 Special riandlrng IrSLrucoor,s and Adoilioro' In`c ma ion <br /> 3L 3 <br /> r 5 Y <br /> r <br /> 16 GENERATOR 5 CERTIFICATION i ce-I *e^c e tis de�c Ices abetc or air res .ie no,=_tbject to iede GI ea ue lonc'c eaer,�-q p,crcr c�potah c1 -ta2wdo,c V,'P,e <br /> 2L� �f��Ed %!ame I Q / Mong`i Oct lcar <br /> T 1 17 iransperer Acknc%Nleoge•nent ct Pece p of I'a E'a s A �J <br /> r R <br /> A i-t,ec T}ped Name l sicJ u 1 L !} r'on 03} Year <br /> A L! <br /> O 18 Tr.nspe"er 2 AckncmIedge ment of Rcceipl of Ma era s <br /> R - <br /> T Prin cc,T�ped Name I Signature PAD,ti Day }ear <br /> EIR <br /> t <br /> 19 DiscreparCy Endicaoon Space <br /> F <br /> A <br /> C <br /> I <br /> 20 Facillt� Qk,ner or Operator Cenuicalion of receipt&1%81,0 materials cove ed h5 tti° manifest excep,as noted in hem 19 <br /> Y 170nr17 Da Year <br /> nnteo%T�pod N-rne Signal � Y <br /> Printed by J J KELLER 6 ASSOCIATES INC 12-BLS-05 Rev 12/98 <br /> Neenah ti,ls<as7-0sss ORIGINAL — RETURN TO GENERATOR <br />