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w - <br /> ,,(5arm 4� orarsaoa eltle t2p1 �s �. <br /> NON-HAZARDOUS 1 Generators U EPA ID N0 banded Doc No 2 Pagel <br /> WASTE MANIFEST �j 0f <br /> 3 Gene rato Nam analfing Address <br /> W ID <br /> 4 Generator s Phone( ) L ��ai� Tim <br /> 5 Transporter 1 Company Name 6 US EPA ID Number A Transporte Phone <br /> 7 Transponer 2 Company Name 8 USE A ID Number B Transporters Phone <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Fac lily s Phone <br /> �-Y /q <br /> 13 1 <br /> 11 Waste Shipping Name and Description 12 Conta Hers Total Und <br /> '11 No Type OuanWy WUV01 -� <br /> a U/jvt <br /> I ✓C/�1 <br /> G b <br /> E <br /> N <br /> E <br /> R t <br /> T c rpt <br /> R d -s <br /> I � <br /> r t <br /> D Addit+oral Descr pions for Vale ials Lis ed Above E Nandi)^g Codes for Was+es Listed Above <br /> r <br />� - v <br /> 3 <br /> 15 Special Nandlirg InSi uctionS and Addi ierai Informarion <br /> (1/�-e2 -3/03 <br /> rt <br /> I <br /> I <br /> f - <br /> r _ <br /> f 16 GENERA70R 5 CERTIFICATION ce^ a me c ais ce,cr bed a.,c,e tr, i- randest,ie no �.ticC tc fcdc al reo-io ions er eoorirg p oxer c,5pasM o riaze XJLLS+'iasie <br /> Pnr P T1 pEd Jam <br /> � I � <br /> T -R rspo-e 1 ACK^C% IC r int of Rece+ot of V-a c ials <br /> — <br /> A Print d"Tt�ed Nate <br /> N <br /> S <br /> P ' <br /> O 18 Transpcnar 2 ACK Cs iedcemerl e Rece pt of Mate is}s <br /> R ' <br /> R I Prinled,7�peo Name S gnalure I Non n O.y I yea, <br /> L 19 Discrep2nc� indica ion Space <br /> F <br /> A <br /> C <br /> 1 <br /> L 20 Facih.y Or rer or Operator t�erilicatien of receipt Of%%3sfe maienals Cote ed by this manifest except as noted rn Iters 19 <br /> loon n Day year <br /> FointedrTName ame Signature <br /> ?nnted ey J J KELLER d ASSOCIATES INC 12-BLS-05 Rev 12198 <br /> Neenah WI 54957-0368 <br /> ORIGINAL, — RETURN TO GENERATOR <br />