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xN <br /> NOIR-HAZARDOUS 1 Generator's US EPA ID No Manifest Doc No 2 Page 1 <br /> WASTE MANIFEST Of � <br /> 3 Generator's Name and Mailing Address <br /> 4 Generator's Phone( �� <br /> 5 Transporter 1 Company Name 6 US EPA ID Number A Transporter's Phone <br /> 6A 25 I(V <br /> 7 Transporter 2 Company Name 8 US EPA ID Number B Transporter's Phone <br /> 9 Designated Name and Site Address 10 US EPA ID Number C Facility's Phone <br /> 11 Waste Shipping Name and Descnption 12 Containers 13 14 <br /> Total Unit <br /> No IType Quantity WI/Vol <br /> a <br /> G b <br /> E <br /> N <br /> E <br /> R <br /> A c <br /> T <br /> O <br /> R <br /> d <br /> D Additional Descriptions for Materials Listed Above E Handling Codes for Wastes Listed Above <br /> 15 Special Handling InstructionsandAdditional Information <br /> ndest are not sublet!to federal regulations far reporting proper disposal of Hazardous Waste <br /> 16 GENERATOR S CERTIFICATION I certify the materials described above on this <br /> Print yped Name Lure \�''" / Month Day Yaar <br /> TR 17 Transporter 1 Acknowledgement ON Receipt of Materials <br /> N PedLTyped Name nature ( Month Day Year <br /> S _ f� s 3 3 <br /> P <br /> R 18 Transporter 2 Acknowledgement of Re elpt of Materials <br /> E Pnnted/Typed Name Signature Month Day Year <br /> R <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> 20 Facility Owner or Operator Certification of receipt of to material overed by this manifest xcept as noted In Item <br /> I� <br /> Y Pnnted/Typed Name Signal — ont <br /> r - <br /> 'K� <br /> 61 by J J KELLER&ASSOCIATES,INC <br /> WJ W57-03ta n 12 LS-05 Rei 12158 <br /> +. TRANSPORTER #1 <br />