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�r <br /> „xFam'da9iyrl �adfor�rfseorl a a2 � �=-p: ar _ �r'�'�` _ -"t6=da"� <br /> NON-HAZARDOUS t Generators US EPA No Manttest DOC No 2 Page 1 <br /> WASTE MANIFEST /� C of F <br /> 3 Generator s Name and Mailing Address r, <br /> 4 Generators P hone{ �G) �� y <br /> 5 Transporter'I Company Name 6 US PAID Number A Transporler's Phone <br /> /V//4- <br /> 7 Transporter 2 Company Name B US PA lD Number B Transporler s Phone <br /> R, <br /> 9 Designated Facddy Name and Site Address 50 US EPA ID Number C Fac0ity s Phone13 14 <br /> F <br /> i 11 Waste Shipping Name and Description 12 Containers Total Unit <br /> No Type Quantity Wtrvol Pus <br /> Nati <br /> a �1 di�J PAZ <br /> G b <br /> E y, <br /> F N <br /> E <br />_ R k`% <br /> - A c c' <br /> L. p Y <br /> h <br /> - R <br />) _ d <br /> I <br /> r D Addi�roral Descnp tuns to l✓,arErlalS Lr51ed Aboi e E Hzndhr g Cooes for Ydostes Lis'ed Aboi e <br /> F96-w -1A <br /> r <br /> 5 Special 'ardhno Instrcc icr:end Adclsonal In'o a ion t <br /> r <br /> y r . <br /> r <br /> 16 GENERATOR S CERTIFICATION I cc- t the = c s ocsc ced Oc�e on s—a-r e-a e no s�bjcc1 to eda zl regua io�c for cTorirg proper d spetal o Hazarde­s 4.r,e i <br /> Pnn edrT�OEG Nlia-ie \r I Sir j Jor I Dov led <br /> i <br /> 17 17 Transponer Ac no 'edperne-of Pece pf of F ei F s <br /> R <br /> A (T1_ lTt;,?6I aatre Sr9r iL P n ass D-v fear <br /> i <br /> ' Pi <br /> R l8 Transponer 2 Acknci ledgement cf Receipt of Ma er=s f <br /> T Printed/Tiped Name I Sioralire rronrn pry rear <br /> R <br /> 19 Discreparcy Indication Space <br /> F <br /> A <br /> C <br /> f <br /> 20 Fac Inq O+ner or Operator Cendication of rece+pl c'%%rite ma'enals coverec by this manifest except as noted in Item 19 <br /> Y Si natur floniR C+y <br /> Pnnted74ped fvame g � �ev <br /> Pnrded by J KELLER B ASSOCIATES INC 12-BLS-05 Rev 12198 <br /> Neenah WI 54957.0.468 <br /> ORIGINAL — RETURN TO GENERATOR <br />